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Addresses  and  Essays 

— BY  — 

G.  FRANK  LYDSTON,  M.  D„ 

Professor  of  the  Surgical  Diseases  of  the  Genito-Urinary  Organs  and 
Syphilology,  in  the  Chicago  College  of  Physicians  and  Surgeons : 
Surgeon-in-Chief  of  the  Genito-Urinary  and  Venereal  De- 
partment of  the  West  Side  Dispensary,  Chicago; 

Fellow  of  the  Chicago  Academy  of  Medicine 
and  of  the  Southern  Surgical  and 
Gynfecological  Association ; 

Lecturer  on  Criminal  Anthropology  in  the  L^nion  iLaw  Bchool;  Hon- 
orary Member  of  the  Texas  State  Medical  Association ; etc. 


(SECOND  EDITION.  REVISED  AND  ENLARGED  ) 


Published  by 

RENZ  & HENRY, 


Louisville,  Ky. 


Copyrighted  1892. 
By 

RENZ  & HENRY, 
Louisville,  Ky. 


ADDRESSES  AND  ESSAYS. 


LYDSTON. 


Digitized  by  the  Internet  Archive 
in  2016 


https://archive.org/details/addressesessaysOOIyds 


PUBLISHERS  PREFACE. 


In  presenting  this  collection  of  Prof.  Lydston’s 
Addresses  and  Essays  to  their  professional  friends, 
the  publishers  trust  that  the  work  will  be  more  accep- 
table as  an  addition  to  the  library  than  a cut  and 
dried  text  book.  Every  practioner  is  supposed  to  be 
provided  with  treatises  upon  the  various  branches  of 
medicine,  and  it  is  hoped  that  the  more  thoughtful  of 
the  profession  will  be  more  favorably  inclined  toward 
a volume  of  original  essays  than  an  ordinary  medical 
treatise  which  would  be  but  a repetition  of  what  their 
libraries  already  contain. 


WILLIAM  E.  QUINE,  M.  D. 


PUOFESSOn  OF  THF>  PHINCIPLES  AND  PRACTICE  OF  MEDICINE  AND  CLINICAL 
MEDICINE  IN  THE  CHICAGO  COLLEGE  OF 
PHYSICIANS  AND  SURGEONS, 

IN  TESTIMONY  OF  APPRECIATION  OF  IIIS  GREAT  ABILITY  AS  A TEACHER  AND 
CLINICIAN,  AND  AS  A TRIBUTE  OF  PERSONAL  ESTEEM  THIS 
IBOOK  IS  RESPECTFULLY  DEDICATED  BY 


THE  AUTHOR. 


PREFACE  TO  THE  SECOND  EDITION. 


The  present  volume  contains  in  a revised  and 
enlarged  form  a series  of  essays,  addresses  and  lec- 
tures published  in  various  quarters  for  several  years 
past.  The  first  edition  was  received  so  kindly  by  the 
profession  that  the  author  has  been  encouraged  to 
publish  a more  pretentious  volume.  The  essay  on 
Sexual  Perversion  has  been  added  chiefly  because  of 
the  great  interest  which  was  taken  in  the  original 
article,  as  manifested  by  numerous  requests  for  re- 
prints which  have  been  received.  The  author  has 
been  pleased  to  note  that  during  the  active  discussion 
upon  sexual  perversion  which  has  been  excited  by 
recent  sensational  murders  by  sexual  perverts,  the 
classification  contained  in  his  essay  has  been  quite 
extensively  adopted.  The  author  is  especially  grati- 
fied to  observe  that  Dr.  J.  G.  Kiernan,  one  of  the 
ablest  of  American  alienists,  has  recently  accepted  the 
classification  although  he  criticised  it  when  it  was 
first  published.  The  essay  upon  Criminal  Crania  is 
but  a fragment  of  a work  now  in  preparation  and 
is  necessarily  incomplete.  The  article  on  Varicocele 
comprises  a paper  presented  to  the  Southern  Surgical 
Association  in  1890,  and  is  an  excerpt  from  a recently 
published  complete  monograph  upon  the  subject. 

Opera  House  Block,  Chicago, 

September  ist,  1892. 


TABLE  OF  CONTENTS. 


Page. 

Evolution  of  the  Local  Venereal  Diseases 1 

Gonorrhoea  in  Women 1 ^ 

Hypertrophy  and  Hyperplasia  Consequent  upon  Lesions 

of  the  Genitalia 

Aberrant  Sexual  Differentiation -13 

A Plea  for  Early  Operation  in  Acute  Peritonitis t!> 

Studies  of  Criminal  Crania "=  h.) 

Materialism  vs.  Sentiment  in  the  Stud3"  of  Crime ID 

The  Rationale  of  Extension  of  the  Spine IhS 

Tropho-Neurosis  in  the  Phenomena  of  Syphilis Hi 

Varicocele 1^3 

Observations  on  Stricture  of  the  Crethra P*3 

The  Treatment  of  Sj'philis -'1' 

Sexual  Perversion '--13 

Urethral  and  Genital  Neuroses 

A Case  of  Circinate  Papulo-ErjThematous  Syphilide  with 

Psoriasis  Palmaris  Si^philitica -P* 


THE  EVOLUTION 

— OF  THE — 

LOCAL  VENEREAL  DISEASES. 


It  was  invariably  taught  until  quite  recently  that 
the  viruses  of  chancroid  and  gonorrhoea  were  specific 
entities  which  were  always  and  invariably  the  same, 
their  inoculation  being  followed  under  all  circum- 
stances by  similar  and  typical  results.  Indeed  T 
myself  accepted  this  view  so  confidently  that  it  is  with 
some  hesitancy  that  I will  endeavor  to  present  views 
that  are  diametrically  opposed  to  those  which  I form- 
erly believed  to  be  correct.  When  Drs.  Taylor  and 
Bumstead,  in  their  excellent  work  upon  the  venereal 
diseases,  advocated  the  doctrine  that  the  chancroidal 
virus  was  not  a specific  entity,  and  that  chancroidal 
ulcerations  differed  in  degree  only,  rather  than  kind, 
from  ulcers  of  a simple  character,  there  were  very 
few,  indeed,  who  did  not  antagonize  their  views.  It 
is  only  within  a very  short  time  that  I have  been  con- 
vinced, from  observation  and  experience,  that  chan- 
croid and  gonorrhoea  are  diseases  which  may  arise 
de  novo,  and  which,  in  the  true  sense  of  the  term,  are 
not  specific.  It  appears  to  me  that  it  is  only  by  the 
acceptance  of  this  theory  that  it  is  possible  to  under- 
stand something  of  the  origin  of  chanchroid  and 
gonorrhoea,  and  which  we  certainly  cannot  do  under 
the  old  and  generally  accepted  doctrine  of  specificity. 

While  we  may  not  be  able  to  positively  demon- 
strate the  origin  of  the  poisons  of  all  infectious  dis- 


* Address  before  the  St.  Louis  Academy  of  Medicine 


— 2 — 


eases,  it  is  difficult  to  comprehend  that  a “specific” 
poison  has  always  existed  in  any  case,  and  it  is  cer- 
tainly a great  step  in  the  advancement  of  medical 
science  when  we  became  able  to  trace  the  poison  of 
any  particular  specific  disease  to  its  source.  We 
have  not  been  able  to  do  this  with  many  diseases,  for 
it  is  fully  as  difficult  to  understand  the  circumstances 
under  which  certain  morbid  entities  affecting  the 
human  body  sprang  into  existence,  as  it  is  to  compre- 
hend the  precise  conditions  under  which  vitality  itself 
first  made  its  appearance  in  matter  hitherto  inert.  A 
few  of  the  morbid  conditions  affecting  animal  life 
have  fortunately  been  traced  to  their  origin,  and, 
through  the  germ  theory,  we  have  at  last  begun  to 
see  a little  light  in  regard  to  the  origin  of  infectious 
diseases.  Even  at  the  present  day,  however,  very 
few  scientists  are  looking  in  the  proper  direction  for 
the  origin  of  disease,  for  if  we  admit  that  the  germs 
of  disease  are  living  entities,  why  is  it  not  logical  for 
us  to  bring  to  bear  upon  them  the  same  laws  of  evo- 
lutionary progression,  differentiation,  and  develop- 
ment that  we  now  apply  to  all  other  living  creatures? 

Disease  is  incident  to  the  life  of  every  animal,  and 
as  we  study  the  evolution  of  the  a mal,  so  should  we 
study  the  evolution  of  its  diseases.  Every  phase  of 
animal  development  and  progression  is  subject  to  ad- 
verse elements  of  various  kinds  ; thus  each  animal  is 
relentlessly  pursued  by  foes  of  a higher  or  lower 
evolutionary  development.  Man,  with  his  superior 
power  born  of  knowledge,  has  been  able  to  contend 
successfully  with  all  of  those  elements  which  are 
inimical  to  his  welfare,  with  the  exception  of  those 
apparently  insignificant  little  organisms — the  germs 
of  disease.  As  man  himself  has  become  differentiated 
through  varying  circumstances  of  environment,  so  have 
his  foes  become  differentiated  ; hence  he  has  become 
more  susceptible  to  the  inroads  of  certain  forms  of 
disease-germs,  but  less  susceptible  to  others  ; certain 
varieties  of  germs  have  become  extinct,  while  new 
forms  have  been  developed  ; others,  again,  have  be- 
come so  modified  as  to  bear  almost  no  resemblance 
to  the  parent  stock.  By  pursuing  this  line  of  study 


we  may  eventually  find  that  many  diseases  which  are 
now  apparently  quite  dissimilar,  have  become  so  by 
the  differentiation  of  the  germs  upon  which  they 
depend,  and  perhaps  may  discover  the  circumstances 
which  have  brought  about  such  differentiation. 

In  applying  this  theory  to  chancroid,  I first  desire 
to  call  your  attention  to  a few  analogical  arguments 
that  are  certainly  striking.  We  will  take  as  our  point 
of  departure  diseases  of  a known  or  alleged  specific 
nature,  and  see  if  we  cannot  find  elements  in  two 
forms  of  the  same  disease  which  are  more  dissimilar 
than  are  simple  genital  ulcers  and  chancroid.  In 
small-pox  we  note  several  degrees  of  severity,  from  a 
varioloid,  in  which  there  perhaps  exists  but  a single 
pustule,  to  the  variola  haemorrhagica,  or  maligna, 
which  is  so  fatal  to  life.  The  resemblance  between 
these  two  extremes  is  very  slight,  yet  they  are  the 
same  disease.  Or,  to  go  still  farther,  .note  the  differ- 
ence between  small-pox  and  vaccinia.  Not  much  re- 
semblance between  the  two  you  will  admit,  yet  the 
poison  of  the  latter  is  a derivative  of  the  former,  and 
by  its  action  the  human  system  is  rendered  insuscepti- 
ble to  the  attacks  of  its  more  vigorous  and  noxious 
ancestor. 

In  scarlatina  we  have  all  grades  of  severity,  from 
the  walking  form,  in  which  one  would  hardly  know 
that  the  child  is  ailing,  to  the  scarlatina  anginosa,  or 
maligna,  in  which  the  life  of  the  little  victim  is  so 
rapidly  destroyed.  A singular  fact  is  that  in  the 
severe  forms  of  scarlet  fever  the  angina  assumes 
characteristics  so  severe,  and  of  so  peculiar  an  appear- 
ance, that  the  doctor  is  sometimes  impelled  to  say, 
“ This  child  also  has  diphtheria.”  Do  you  believe  that 
the  system  of  the  child  could  be  a field  for  strife  between 
two  infectious  constitutional  diseases  of  so  pronounced 
a type?  I do  not;  but  I am  convinced  that  these 
cases  are  an  illustration  of  the  manner  in  which  cer- 
tain diseases,  supposed  to  be  separate  and  distinct, 
are  co-related;  and,  furthermore,  of  the  possibility  of 
their  development  de  novo. 

Typhoid  and  typhus  fevers  have  numerous  degrees 
of  severity,  the  extremes  of  which  are  strikingly  dis- 


— 4 — 


similar,  although  the  viaie7-ies  mo7-bi  is  invariably  the 
same  in  each  instance.  We  know,  too,  that  typhoid 
and  typhus  fevers  may  develop  de  7wvo,  under  favor- 
able circumstances  of  environment.* 

Malarial  fevers  vary  in  severity  from  a slight  ague 
shake  followed  by  fever  to  the  pernicious  t}^pe  which 
speedily  destroys  life.  Clinically,  malarial  and  typhoid 
fevers  are  frequently  confused.^ 

Septic  infection  in  surgical  diseases  may  result  in 
one  of  several  degrees  of  severity  of  blood-poisoning, 
from  the  slight  febrile  disturbance,  which  was  formerly 
termed  “ traumatic  fever,”  to  the  overpowering  and 
speedily  fatal  septsemia,  which  is  so  nearl}''  identical 
to  snake-bite  in  its  effects  upon  the  blood.  Interposed 
between  the  two  we  have  acute  and  chronic  p5^$mia. 
These  phases  of  disease  differ  widely,  yet  they  are  one 
and  the  same,  and  due  to  the  same  cause.®  Erysipelas 
is  a disease  which  may  vary  in  t}^pe  from  the  slight 
form  of  inflammation  which  is  hardly  more  than  an 
erythema,  to  such  a severe  form  as  that  which  some- 
times affects  the  scrotum,  and  not  onl}^  causes  slough- 
ing but  often  a fatal  result.  Can  we  detect  the 
slightest  resemblance  between  the  two  ? I think  not; 
yet  they  are  the  same  disease.  Inoculate  5'our  finger 
with  blood  drawn  from  a patient  with  erysipelas  of 
the  face,  and  you  may  escape  er5"sipelas  entirel)'  ; if 
you  do  not  it  is  apt  to  occur  In  a mild  form.  If,  on 
the  other  hand,  you  inoculate  yourself  with  the  secre- 
tions from  a sloughing  scrotum,  and  you  do  not  die 
of  septsemia,  the  least  you  can  expect  is  phlegmonous 
erysipelas  of  a severe  and  dangerous  type. 

I would  also  call  to  your  attention  the  vast  differ- 
ences which  exist  between  the  different  forms  of 
puerperal  disease;  thus,  we  meet  with  cases  of  peri- 
tonitis, cellulitis,  phlebitis,  and  acute  fatal  septsemia, 

’ This  was  strikingly  illustrated  by  the  epidemic  of  typhus  fever 
which  occurred  in  New  York  in  1880-81. 

“ When  absorbed  by  the  lungs  hospital  miasm  has  been  known 
to  produce  effects  closely  resembling  malarial  poisoning,  and  cur- 
able by  quinine. 

®With  due  deference  to  the  recentl}' published  papers  of  Dr. 
Senn  upon  pyaemia,  in  which  if  I interpret  him  correctly,  an 
opposite  view  is  expressed. 


— 5 — 


all  due  to  the  varying  conditions  and  effects  of  the 
same  materies  inorbi. 

Further  illustrations  are,  perhaps,  unnecessary,  but 
I must  not  omit  the  most  important  analogy  of  all, 
viz.,  diphtheria:  Recent  observations  of  a clinical  char- 
acter have  shown  us  that  the  diphtheritic  virus,  germ, 
influence,  or  whatever  you  may  choose  to  term  it,  is 
capable  of  producing  many  different  phases  of  disease 
of  the  naso-pharynx,  varying  from  a slight  and,  appar- 
ently, simple  sore  throat  with  little  or  no  constitutional 
symptoms  (catarrhal  diphtheria),  to  an  exudative 
malignant  affection  capable  of  rapidly  destroying  life, 
and  invariably  producing  the  most  profound  constitu- 
tional disturbance.  We  know  that  Epidemics  of  sim- 
ple sore  throat  are  closely  associated  with  epidemic 
diphtheria.  With  the  coming  and  going  of  an  epi- 
demic of  diphtheria  especially,  as  well  as  during  its 
maximum  dissemination  throughout  a community,  we 
observe  many  cases  which,  while  they  do  not  present 
the  typical  characters  of  diphtheria  and  the  diphthe- 
ritic micrococcus  cannot  be  found  in  the  pharyngeal 
secretions,’  are  nevertheless  due  to  the  same  influences 
as  diphtheria  proper.  When  diphtheria  exists  in  a 
family  of  several  persons,  it  is  often  observed  that 
apparently  simple  sore  throat  will  appear  in  some 
members  of  the  family  while  others  are  affected  by 
genuine  diphtheria,  and  that  the  simple  cases  often 
become  transformed  into  the  more  malignant  type. 
Physicians  in  attendance  upon  cases  of  diphtheria  are 
often  affected  by  sore  throat  of  greater  or  less  severity; 
this  being  my  own  experience  whenever  I attend 
cases  of  this  character  for  any  length  of  time.  A de- 
fective drain  has  been  known  to  affect  different  mem- 
bers of  the  same  family  with  morbid  conditions  of  the 
throat,  varying  from  trifling  soreness  to  malignant 
diphtheria,  and  also  with  varying  types  of  essential 
fever.^ 

’ Some  of  the  more  recent  investigations  tend  to  show  that 
there  are  several  forms  of  micro-organisms  found  in  diphtheria, 
none  of  which  are  characteristic,  and  all  of  which  are  found  upon 
the  normal  mucous  membranes. 

“Lee,  Dr.  L.  J.  W, : Influence  of  Diathesis  upon  Contagion. 
New  York  Medical  Record,  vol.  xxv,  No.  v,  p.  84. 


— 6 — 


I have  mentioned  these  many  facts,  which  are 
apparently  so  foreign  to  the  subject  of  chancroid  and 
gonorrhoea,  to  demonstrate  the  varying  results  which 
may  be  produced  by  the  evolution  of  the  same 
poison. 

Now,  what  is  the  reason  that  these  so-called  specific 
poisons  manifest  themselves  so  differently  under  ap- 
parently identical  circumstances?  Simply  a varying 
virulency  of  the  poison  upon  the  one  hand,  and  vary- 
ing susceptibility  upon  the  other,  these  variations 
being  comprehensible  to  me  only  upon  the  hypothesis 
of  evolutionary  changes  in  the  germ  as  well  as  in  its 
field  of  action,  i.e.,  the  human  S3^stem.  Let  us  con- 
sider this  hypothesis,  and  see  if  the  variation  of  the 
phenomena  of  disease  is  not  dependent  upon  a varia- 
tion in  what  has  heretofore  been  considered  an  unvary- 
ing entity — a specific  germ — and  if  even  the  noxious 
or  poisonous  property  of  the  germ  may  not  be  an 
ingraft  upon  it,  or  at  least  a matter  of  development. 
Let  us  take  as  our  first  point  of  departure  those  inno- 
cent germs,  cocci,  or,  if  you  please,  minute  organized 
particles  which  everywhere  exist  in  the  atmosphere. 
These  germs  multipl}^  by  their  own  peculiar  methods 
of  procreation,  and  such  multiplication  is  favored  or 
opposed,  as  the  case  may  be,  according  to  their  en- 
vironment. Filth,  heat,  and  moisture,  and  protection 
from  air  and  light,  favor  the  development  of  many 
such  organisms.  It  is  obvious  that  successive  crops 
of  germs  are  possessed  of  properties  which  diverge 
more  or  less  from  those  of  the  parent  stock.  This  is 
a universal  law  that  applies  to  all  living  organisms. 
The  newl}^  acquired  properties  are  modified  or  varied 
according  to  var3ung  circumstances  of  environment. 
Whether  it  is  the  germs  proper,  their  secretions  or 
excretions,  if  such  there  be,  or  new  and  complex  com- 
pounds produced  b3^  their  action  upon  putrescible 
matter,'  that  produce  their  peculiar  effects  upon 
organisms  more  highly  differentiated  than  themselves, 
it  would  be  difficult  to  determine,  but  it  is  at  least 
conceivable  that,  sooner  or  later  in  the  process  of 


’ Ptomaines  or  leucomaines. 


— 7 — 


evolution,  germs  are  developed  which  are  possessed 
of  properties  by  virtue  of  which  they  are  capable  of 
producing  definite  effects  upon  the  human  system. 
Thus  we  have,  by  evolution,  the  spontaneous  gener- 
ation of  so-called  specific  poisons.  Now,  do  not 
understand  me  to  say  that  the  germs  themselves  are 
spontaneously  developed,  for  while  such  an  event  is 
perhaps  possible,  it  is  as  yet  disputed  by  the  best 
scientific  authorities.  What  I do  claim  is,  that  the 
poison  of  disease  may  be  developed  by  the  evolution 
of,  and  acquirement  of  new  and  toxic  properties,  by 
germs  which  were  primarily  innocuous. 

Having  arrived  at  a stage  of  development  when  it 
is  capable  of  producing  definite  morbid  effects  upon 
the  system,  we  might  suppose  that  this  germ  would 
cause  invariably  similar  effects  upon  the  human  econ- 
omy. But  the  law  of  evolution  still  follows  the  germ 
of  disease  in  its  tour  of  mischief,  and  as  I have 
attempted  to  show  you  from  a clinical  standpoint, 
modifies  the  resulting  phases  of  disease  most  mark- 
edly, independently  of  the  special  properties  of  the 
individual  germ. 

The  conditions  modifjdng  the  results  of  germ  infec- 
tion are,  as  nearly  as  I can  understand  them,  as  fol- 
lows: 

1.  The  degree  of  virulency  and  vitality  of  the 
germ  at  the  time  it  enters  the  tissues  or  blood  of  a 
human  being. 

2.  The  inherent  vitalit}^  of  the  individual,  or  his 
resisting  power  at  the  time  of  infection. 

3.  Individual  susceptibility  to  the  particular  dis- 
ease represented  by  the  germ,  i.  e.,  idios}mcrasy. 

4.  The  condition  of  the  eliminative  apparatus  of 
the  person  affected. 

5.  If  the  disease  germ  has  a special  predilection 
for  any  particular  tissue  the  result  will  be  modified 
by  the  condition  of  that  tissue  at  the  time  of  its  infec- 
tion, e.  g.,  the  t3^phoid  bacillus  and  the  comma  bacil- 
lus of  cholera  Asiatica  most  readily  affect  those  who 
have  morbid  conditions  of  the  alimentary  canal. 
Diphtheria  is  most  apt  to  attack  persons  with  acute 
or  chronic  naso-pharyngeal  disease. 


— S-' 


6.  And  one  of  the  most  important  of  all,  the  num- 
ber of  germs  and  the  length  of  time  during  which  the 
patient  is  exposed  to  their  influenced 

Although  not  usually  attributed  to  evolutionary 
laws,  some  of  these  ideas  in  relation  to  the  develop- 
ment of  infectious  diseases  are  already  pervading  the 
profession  to  a slight  extent.  Probably  the  nearest 
approach  to  a thorough  exposition  of  the  subject  is 
an  essay  by  Dr.  De  Gorrequer  Griffith,  of  London, 
entitled  the  “Unity  of  Poison.”-  In  this  article  the 
learned  author  has  shown  quite  plainly  the  corelation 
of  certain  infectious  diseases  formerly  supposed  to  be 
separate  and  distinct  affections. 

Now  to  attempt  the  application  of  this  theory  of  the 
spontaneous  development  of  specific  poisons  to  the 
development  of  the  viruses  or  germs  of  the  local  vene- 
real diseases : 

The  idea  that  the  chancroidal  poison  is  one  which 
has  always  been  inseparable  from  the  human  species, 
is  of  course  untenable.  Somewhere  along  the  line  of  our 
ancestry  chancroid  appeared,  but  at  what  time  history 
does  not  tell  us.  The  human  race  in  general  must 
have  begun  existence  with  a considerable  capital  in 
the  form  of  a healthy  organization,  and  every  disease 
which  now  affects  unfortunate  humanit}’  must  neces- 
sarily have  developed  since  the  species  originated. 
As  the  races  have  become  differentiated,  or  have  di- 
verged, new  circumstances  of  environment  have  been 
encountered  which  have  modified  the  organism  of  the 
human  being,  and  in  the  course  of  evolutionar}"  pro- 
gression many  and  various  diseases  have  arisen. 


* Virchow  has  shown  this  to  be  eminently  true  of  septasmia. 

‘ Midland  Medical  Miscellany.  As  expressed  by  Griffith,  this 
theory  implies  “ the  unity  of  poison  and  differentiation  of  result- 
ant phenomena  which  we  call  symptoms — not  because  of  any  differ- 
ence in  the  poison  which  maybe  the  orig-o  ma/iof  so-called  various 
diseases,  but  differentiations  dependent  upon  the  media  through 
which  the  poison  passes,  or  upon  which  it  falls,  the  evolutions  and 
development  of  that  one  poison  being  marked  by  new  phases,  new 
manifestations  to  which  rightly  we  should  not  apply  the  expres- 
sion ‘ separate  diseases,’ but  rather  call  them  simply  what  they 
are,  the  various  expressions  of  the  evolutions  of  that  unity  of 
origin,  whatever  it  may  be,  which  has  set  then  all  agoing.” 


— 9 — 

This  fact  has  been  due  to — 

I St.  The  appearance  upon  the  scene  of  weaker 
and  more  susceptible  organizations  than  those  of  the 
parent  stock. 

2d.  Changes  of  telluric  and  climatic  influences. 

3d.  Injuries  and  vicissitudes  experienced  in  the 
struggle  for  existence,  modifying  the  organisms  of 
numerous  individuals,  such  modifications  being  trans- 
mitted to  their  descendants. 

4th.  Varying  character  and  quantity  of  food  and 
drink,  alcoholics  within  a considerable  number  of 
generations  having  exerted  a marked  influence. 

5th.  Varying  sanitary  circumstances,  involving 
crowd  poison  and  other  forms  of  noxious  and  contam- 
inating animal  matter. 

6th.  Varying  personal  hygiene,  involving  cleanli- 
ness, exposure  to  cold  and  wet  and  other  influences 
which  may  modify  individual  constitutions.  The 
question  of  sexual  habits  here  enters  mto  considera- 
tion and  is  necessarily  of  special  mportance  in  its 
bearing  upon  the  evolution  of  the  venereal  diseases. 

7th.  The  gradual  and  certain  evolution  and  differ- 
entiation of,  and  acquirement  of  new  properties  by, 
living  germs. 

So  much  for  the  acquirement  of  disease  in  general.' 
Gonorrhoea  and  chancroid  have  probably  arisen  in  a 
manner  precisely  similar  to  the  evolution  of  other  in- 
fectious diseases,  and  while  it  is  premature  to  say 
that  the  poisons  of  the  two  diseases  are  precisely 
identical,  I am  firmly  convinced  that  they  are  differ- 

' Independently  of  the  existence  of  the  living  germ,  attention 
may  be  called  to  the  generally  unappreciated  fact  that  all  poisons 
act  upon  the  animal  body  in  accordance  with  physiological  laws. 
The  physician  speaks  of  the  physiological  effects  of  his  drugs, 
but  strange  to  say,  never  of  the  physiological  effects  of  the 
materies  morbi  of  disease.  The  effects  of  poisons  vary  ; thus, 
opium  gives  a wide  range  of  results,  from  nervous  stimulation  to 
fatal  coma,  aconite  varies  in  its  effects  from  moderate  sedation  to 
cardiac  paresis,  malarial  poison  (or  germs)  from  slight  depression 
of  the  vital  functions  to  fatal  coma,  and  so  on,  ad  infinitum. 
Again,  some  poisons  have  a local  as  well  as  constitutional  effect, 
the  local  changes  which  they  produce  being  also  purely  physio- 
logical. The  science  of  medicine  will  never  become  philosoph- 
ical until  these  facts  are  generally  both  appreciated  and  applied. 


lO 


ent  in  degree  rather  than  kind,  and  of  a similar  origin 
to  say  the  least.  We  are  not  lacking  in  authorities 
who  believe  them  to  be  precisely  the  same.  Dr.  R. 
W.  Taylor  is  one  of  the  leading  authorities  who  claim 
that  chancroid  is  not  a specific  disease  in  the  sense 
that  we  speak  of  variola,  and  that,  moreover,  its 
poisonous  secretion  is  precisely  the  same  as  that  of 
gonorrhoea.  Dr.  F.  R.  Sturgis  also  holds  this  view. 

The  origin  of  gonorrhoea  and  chancroid  must  neces- 
sarily be  the  same,  if  the  evolutionary  theory  of  their 
origin  be  correct.  The  vagina  of  the  female  is  as  ez- 
cellent  a nidus  or  hotbed  for  the  generation  of  poisons 
as  could  be  well  imagined,  and  when  we  consider  the 
large  number  of  women  who  are  affected  by  uterine 
or  vaginal  diseases,  it  is  a matter  of  wonderment  that 
the  venereal  affections  are  so  few  in  number  and  man- 
ifestations. 

There  exists,  even  in  perfectly  healthy  women,  the 
circumstances  of  heat,  moisture,  protection  from  air 
and  light,  and  the  occurrence  very  often  of  local  irri- 
tation in  the  form  of  excessive  cohabitation.  Super- 
add to  these  normal  or  quasi-normal  conditions  a 
suitable  pabulum  for  the  development  of  germs  in  the 
form  of  uterine  or  seminal  discharges,  and  we  are  apt 
to  have  conditions  decidedly  detrimental,  not  only  to 
the  woman  herself,  but  to  the  generative  organ  of  an}' 
one  with  whom  she  may  chance  to  have  sexual  congress. 

Few  women  are  free  from  disease;  indeed,  the 
woman  who  is  perfectly  sound  is  a rai-a  avis,  and  in 
the  uterine  discharges  bacteria  may  develop  and  wax 
fat.  Many  women,  through  ignorance  in  some  cases, 
through  natural  physical  indifference  in  others,  are 
exceedingly  unclean,  and  allow  both  natural  and  un- 
natural secretions  to  accumulate  until  the  condition 
of  their  sexual  organs  is  indeed  filthy.  This  is 
especially  the  case  in  the  low  class  prostitute,  and 
unfortunately  is  often  the  case  among  women  who  are 
respectable  or  qnasi-respectable.  As  has  been  re- 
marked by  others,  in  connection  with  the  subject  of 
urethritis  and  chancroid,  the  high-toned  prostitute  is 
not  so  open  to  impeachment  upon  the  score  of  un- 
cleanliness as  those  of  a lower  grade.  In  a general 


way  it  may  be  said  that  if  every  man  could  view  for 
himself  the  actual  condition  of  most  of  the  women  ol 
easy  virtue  with  whom  he  is  brought  in  contact,  there 
would  be  a decided  improvement  in  the  moral  tone 
of  the  community.  I may  also  add,  that  with  the 
present  unhealthy  manner  of  living  in  vogue  among 
the  fair  sex,  many  young  men  would  give  up  all 
romantic  ideas  of  matrimony,  if  they  could  but  inspect 
the  object  of  their  ambition  through  the  speculum  of 
the  gynaecologist.  So  much  for  uncleanliness  and 
disease,  independent  of  the  question  of  virtue  and 
morals. 

As  the  circumstances  of  uncleanliness,  unhealthy 
secretions,  local  irritation,  heat,  moisture,  and  depri- 
vation of  free  air  and  light  favors  the  development  of 
germs,  and  particularly  those  of  decomposition,  it 
may  be  readily  understood  that  after  a time  such  a 
bacterial  development  actually  takes  place  in  the 
vaginae  of  some  women.  The  innocuous  germs  of 
the  atmosphere  enter,  and  begin  their  work  of  procrea- 
tion or  multiplication  in  an  environment  scanty  in  its 
supply  of  oxygen,'  decomposition  occurs,  and  pari 
passu  with  its  new  germs  appear  upon  the  scene  which 
differ  from  the  parent  stock;  and  so  the  process  goes 
on  until  a very  irritating  poison  is  developed.  If  dur- 
ing this  time,  the  discharge  from  a diseased  urethra  be 
added  to  the  noxious  materials,  or  if  semen  be  de- 
posited in  this  hot-bed  of  putrefaction,  so  much  the 
better  for  the  development  of  a “specific”  poison. 
Selmi  and  Gautier  have  shown  that  poisonous  alka- 
loids develop  from  putrefaction,  and  it  is  to  these 
poisonous  substances  or  ptomaines  that  I am  inclined 
to  attribute  the  trouble  in  gonorrhoea  and  chancroid. 
The  decomposition  of  semen  is  especially  likely  to 
produce  such  a poison.  If  this  be  correct,  it  is  to  the 
products  of  the  bacteria,  rather  than  to  the  bacteria 

The  experiments  of  Pasteur  on  chicken  cholera  are  well- 
known.  In  hope  of  diminishing  the  infective  power  of  this 
organism,  he  grew  it  in  oxygen  for  a long  time,  and  found  not 
only  that  it  produced  a modified  disease,  but  that  this  attack  in 
most  cases  protected  the  animal  from  the  effect  of  the  organisms 
in  their  most  virulent  state  !” — British  Medical  Journal,  Decem- 
ber 31,  1881,  p.  1063. 


12 


themselves,  that  we  must  attribute  the  results  of 
chancroidal  and  gonorrhoeal  secretions.  It  is,  there- 
fore, assumed  that  while  bacteria  may  be  present  in 
cases  of  gonorrhoea  and  chancroid,  they  are  by  no 
means  necessarily  so.  This  would  explain  why  scien- 
tific observers  have  found  bacteria  or  cocci  in  some 
cases,  while  they  have  been  unable  to  do  so  in  others. 
The  varying  degree  of  acridity  and  quantity  of 
ptomaines,  and  the  varying  susceptibility  of  mucous 
membranes  would  explain  the  differences  which  appear 
to  exist  between  gonorrhoea  and  chancroid,  as  well  as 
between  mild  and  severe  types  of  the  same  disease.' 

Now  as  to  the  conditions  which  modify  the  results 
of  the  virus  generated  de  7iovo  in  the  human  vagina. 
These  are  as  follows  ; 

ist.  It  is  obvious  that  much  depends  upon  : a,  the 
age  of  the  decomposition  ; b,  the  degree  of  inflamma- 
tion present  ; c,  the  frequency  of  coitus  ; d,  the  con- 
stitution and  habits  of  the  woman  ; e,  the  character 
of  any  semen  or  urethral  discharges  which  may  be 
deposited  in  the  vagina  ; f,  the  degree  of  cleanliness 
of  the  woman. 

2d.  The  amount  and  degree  of  virulency  of  the 
virus  deposited  upon  the  absorbent  surface  in  another 
individual. 

3d.  The  cleanliness,  local  and  constitutional  condi- 
tion, habits  and  sexual  hygiene  of  the  recipient  of  the 
cultivated  virus. 

4th.  Individual  predisposition. 

With  reference  to  the  latter  point.  Dr.  Jordan 
Lloyd  "has  made  the  following  excellent  remarks : 
“There  can  be  no  doubt  that  some  individuals  con- 
tract— and  even  develop — venereal  disease  much  more 
readily  than  do  others.  There  can  be  no  doubt  that 
all  physicians,  from  the  nature  of  their  calling,  must. 


' Eklund  claims  to  have  found  in  the  secretions  of  both  gonor- 
rhoea and  chancroid  the  characteristics  "gonococcus”  claimed  to 
have  been  discovered  by  Neisser.  He  also  describes  mycelial 
woven  filaments,  termed  ediophyton  dictyodes.  This  parasite  he 
also  claims  to  have  seen  in  both  diseases.  So  far  as  it  goes,  this 
is  confirmatory  of  the  corelation  of  gonorrhoea  and  chancroid.  I 
do  not  except  Bumm’s  experiments  as  conclusive. 


— 13  — 


during  the  course  of  each  year,  be  exposed  to  infec- 
tion of  one  kind  and  another  many  hundreds  of  times. 
I am  not  aware  that  physicians  take  any  particular 
precautions  in  the  way  of  protecting  themselves  from 
these  influences.  Immunity  does  not,  in  every  case, 
depend  upon  their  having  already  suffered  from 
attacks  of  the  various  infectious  diseases.  How  is  it, 
then,  that  they  so  rarely  become  affected  ? It  is  be- 
cause they  have  not  the  predisposition,  whatever  that 
word  may  mean  ; because  their  bodies  do  not  present 
a suitable  nidus  for  the  growth  and  development  of 
the  germs  of  disease.  Again,  in  a class  of  cases  more 
closely  allied,  clinically  and  pathologically,  to  those 
under  discussion,  how  often  do  we  see  among  hospital 
officers  men  who  are  frequently  developing  crops  of 
hospital  furuncles  on  their  hands  and  arms,  others 
with  constantly  recurring  sore  throat,  others  with 
inflamed  wounds  and  lymphatics  from  post-rnorte77i 
abrasions,  while  at  the  same  time  and  under  precisely 
the  same  conditions  there  will  be  men  who,  year  after 
year,  remain  free  from  all  such  troubles.  Suscepti- 
bility of  one  class  of  individuals  to  certain  poisonous 
influences,  or  insusceptibility  of  the  other,  must  be 
the  explanation.  There  is  nothing  more  strange  in  it 
than  in  that  of  many  of  the  well-known  “idiosyncra- 
sies for  example,  the  poisonous  effects  of  eggs  and 
tobacco  on  certain  persons.” 

This  author  further  alludes  to  a certain  class  of 
persons  who  are  familiar  to  every  observant  physician, 
as  “suppuraters.”  This  is  the  class  of  people  in 
whom,  as  we  well  know,  wounds  are  more  likely  to 
heal  by  granulation  than  by  first  intention.  Lloyd 
speaks  of  such  persons  as  follows  : “These  people, 
apparently  of  robust  health  and  iron  constitutions, 
frequently  have  boils  ; when  their  lymphatic  glands 
inflame  ; and  they  often  do,  the  process  more  often 
terminates  in  suppuration  than  resolution  ; trivial 
wounds  in  such  people  do  not  dry  up  at  once,  they 
heal  by  granulation.  I believe  these  suppurators  con- 
tract venereal  diseases  where  ordinary  mortals  escape 
them.”' 

'Birmingham  Medical  Review,  Octooer,  1886. 


— 14 


Under  the  head  of  local  conditions,  phimosis,  para- 
phimosis, balanitis,  posthitis,  and  herpes  not  onl}' 
modify  the  course  of  chancroid,  but  indubitably  act 
as  predisposing  causes. 

As  a consequeuce  of  the  wide  spread  variation  that 
exists  in  the  conditions  which  I have  given  you,  there 
may  result  from  different  inoculations  of  essentially 
the  same  products  of  decomposition  different  degrees 
of  infection.  Thus  the  disease  acquired  by  exposure 
to  such  irritating  material  may  be  : ist,  a simple 
balanitis  or  balano-posthitis,  or  venereal  vegetations  ; 
2d,  simple  urethritis  ; 3d,  a virulent  urethritis  ; 4th, 
simple  venereal  ulcer  indistinguishable  from  advanced 
herpes ; 5th,  classical  chancroid.  As  you  may 
imagine,  I would  find  it  difficult  to  show  you  just 
what  variation  in  the  development  of  the  poison  de- 
termined a gonorrhoea  upon  the  one  hand  and  a chan- 
croid upon  the  other,  but  you  will  be  perfectl}'  safe 
in  assuming  that  comparatively  trifling  differences  in 
the  circumstances  of  the  development  of  the  poison 
as  well  as  the  differences  in  the  local  and  constitu- 
tional condition  and  idiosyncrasies  of  patients,  are 
amply  sufficient  to  account  for  the  difference  in 
results.  We  will  lay  theoretical  considerations  aside 
for  the  moment  and  consider  some  of  the  clinical 
facts  bearing  out  the  theor}^  of  the  development  of 
chancroid  and  gonorrhoea  de  novo,  and  its  corelation 
with  other  and  simpler  affections  : 

ist.  It  is  found  that  the  discharge  from  a virulent 
gonorrhoea,  if  confined  by  a tight  prepuce,  will  cause 
quite  severe  inflammation  and  phimosis  (/.  e.,  balano- 
posthitis).  If  not  speedil}^  relieved,  excoriations  and 
even  ulcerations  wall  result. 

2d.  The  discharge  from  these  lesions,  as  well  as 
that  of  gonorrhoea,  will  oftentimes  produce  a pustule  if 
auto-inoculated.  It  will  generally  produce  some  inflam- 
mation, and  in  experiments  upon  cachectic  patients,  I 
have  known  the  tissues  to  break  down  in  ulceration, 
which,  I am  free  to  say,  appeared  to  me  to  be  iden- 
tical with  some  of  the  simpler  cases  of  chancroid. 

3d.  The  long-continued  contact  of  these  secretions 
with  the  mucous  membrane  often  causes  a crop  of 


— 15  — 


venereal  warts.  These  frequently  result  from  simple 
irritating  secretions,  e.  g.,  in  pregnant  women,  and 
are  an  occasional  complication  of  chancroid. 

4th.  Chancroid  of  the  urethra  is  always  attended 
by  urethritis  of  greater  or  less  severity. 

5th.  Gonorrhoea  and  chancroid  are  often  associ- 
ted  in  the  same  patient,  either  appearing  at  the  same 
time  or  at  such  an  interval  that  one  may  quite  plausi- 
bly be  due  to  infection  by  the  secretion  of  the  other. 

6th.  Both  diseases  are  contracted  from  the  same 
class  of  females,  and  often  from  the  same  woman. 
The  higher  class  of  prostitutes  comparatively  seldom 
convey  either  disease. 

7th.  I have  myself  examined  women  from  whom 
both  diseases  have  been  contracted  by  different  men 
at  different  times,  and  found  them  unclean,  but  at  the 
same  time  free  from  both  acute  and  chronic  vaginitis 
and  chancroid. 

8th.  Any  of  the  urethral  or  genital  lesions  may  be 
followed  by  suppurative  bubo,  differing  chiefly  in 
degree  from  virulent  bubo.  I have  succeded  in  auto- 
inoculating  pus  from  a bubo  secondary  to  severe  bal- 
anitis. 

gth.  It  is  always  difficult  to  say  where  simple  geni- 
tal ulcer  terminates  and  chancroid  begins.  The  test 
of  auto-inoculation  is  hardly  fair,  as  it  simply  tests 
the  degree  of  virulency  of  the  ulcer. 

loth.  The  natural  tendency  of  chancroid  is  to  lose 
its  “specificity”  in  a short  time,  and  hy  a reversion  of 
type  to  assume  the  benign  characteristics  of  a simple 
ulcer. 

I have  been  asked  why  all  cases  of  gonorrhoea  do 
not  present  ulcerations  if  the  poison  be  the  same  as 
that  of  chancroid,  and  why  urethral  chancroids  do  not 
destroy  the  entire  urethra.  Now  let  me  repeat  that 
I believe  the  poisons  are  similar  in  origin  and  kind, 
but  different  in  degree.  To  the  first  question  I would 
answer,  because  the  virus  is  not  so  highly  developed 
as  that  which  produces  chancroid,  and  because, 
moreover,  the  urethra  is  a different  structure  from 
the  glans  penis,  and  is  being  frequently  flushed  out 
by  the  urine.  For  that  matter,  instead  of  pronoun- 


— i6 — 


cing  a case  chancroid  of  the  urethra  and  complicating 
urethritis,  why  not  term  it  a gonorrhoea  with  ulcera- 
tion ? Perhaps  the  former  diagnosis  is  confounding 
the  propter  with  the  post.  In  answer  to  the  second 
question,  I will  state  that  the  reason  for  the  non- 
extension of  urethral  chancroid  is  the  same  as  for  its 
non-extension  when  it  occurs  upon  the  external  sur- 
face of  the  genitals.  As  the  virus  invades  increasing 
areas  of  healthy  tissue,  it  necessarily  meets  wdth  a 
resistance  proportionate  to  the  inherent  vitality  of 
the  cells  of  the  healthy  tissue,  and  as  a consequence, 
unless  the  local  conditions  are  extremely  favorable  to 
the  development  of  noxious  and  irritating  secretions, 
the  activity  of  the  virus  becomes  exhausted  after  a 
time.  In  addition  to  this  fact,  wm  have  the  circum- 
stance that  there  is  more  or  less  inflammation  attend- 
ant upon  chancroid,  and  as  a result  we  have  an  ex- 
udative barrier  of  greater  or  less  extent  thrown  up 
about  the  lesion,  which  opposes  its  progress  to  a cer- 
tain extent.  If,  however,  the  patient  be  uncleanl}'  or 
unhealthy,  or  if  he  be  possessed  of  an  idiosyncrasy 
predisposing  to  phagedaena,  there  is  little  vitalit}'  in 
the  normal  cells  to  oppose  the  inroads  of  the  chan- 
croidal process,  and  so  slight  an  exudative  formation 
that  rapid  destruction  of  tissue  is  liable  to  occur. 
These  latter  points  must  be  taken  into  consideration 
in  our  studies  and  treatment  of  chancroidal  phag- 
edaena and  phagedenic  bubo,  as  they  will  be  of  great 
assistance  to  us  in  actual  practice.* 

Opera  House  Block,  Chicago,  III 


’In  his  recent  Lettsomian  lectures,  Mr.  Jonathan  Hutchinson 
expresses  the  opinion  that  chancroid  usually  occurs  in  persons 
whose  systems  have  been  impressed  by  syphilis  at  some  period 
more  or  less  remote.  In  other  words,  it  is  a mild  manifestation 
of  syphilis  in  a person  who  has  already  been  syphilized.  This 
theory  appears  to  be  as  untenable  as  it  is  striking. 


Gonorrhcea  in  Women.^ 


Gonorrhoea  in  the  female  is  perhaps  more  often  met 
with  in  the  field  of  labor  of  the  gynecologist  than  in 
that  of  the  venereal  specialist.  This  would  seem  from 
a p>'ior-i  consideration  a trifle  paradoxical  ; yet  if  the 
more  advanced  views  be  correct  the  co-relatives  of 
gonorrhoea  and  gleet  in  the  male  are  most  often  con- 
sidered by  the  practitioner  to  be  of  a simple  and  non- 
veneral  character  in  the  female.  A knowledge  of 
these  conditions  in  their  various  phases,  and  a just 
appreciation  of  their  relation,  as  regards  cause  and 
effect,  to  venereal  infection,  is  absolutely  indispensa- 
ble to  the  genito-urinary  surgeon,  hence  a presenta- 
tion of  the  subject  from  a practical  standpoint  requires 
no  apology. 

The  special  consideration  of  the  effects  of  “gonor- 
rhoeal” virus  upon  the  female  sexual  organs  is  of 
great  value,  the  more  especially  as  the  poison, 
germ,  virus,  or  whatever  term  may  be  applied  to  it, 
is  primarily  generated  in  women.  It  is  a peculiar 
fact  that  gonorrhoeal  inflammation  in  the  female  rarely 
presents  a condition  physically  analogous  to  that  ob- 
served in  the  male.  Vaginitis  of  venereal  origin  is 
exceptional  in  women,  and  urethritis,  the  only  real 
analogue,  is  excessively  rare  and  does  not  often  occur 
even  when  virulent  vaginitis  exists.  The  rarity  of 
virulent  vaginitis  even  among  that  numerous  class 
from  whom  the  male  acquires  the  disease,  is  only 
explicable  by  the  circumstances  : (ij  Of  the  exist- 

ence in  the  female  of  latent  gonorrhoeal  processes  of 
a greater  or  less  degree  of  virulence.  (2)  Of  the 
acclimation  of  the  vaginal  mucous  membrane  to  the 
toxic  products  of  organic  decomposition  gradually 
formed  in  the  female  generative  apparatus.  If  the 
proposition  be  accepted  that  the  urethra  of  the  male 
may  become  acclimated  to  the  morbid  conditions 
existing  in  the  female,  as  often  seen  in  the  husband 


* From  the  Author’s  Monograph  on  Gonorrhoea,  Physician’s  Leis- 


i8 


GONORRHffiA  IN  WOMEN. 


of  a woman  who  is  poisonous  to  any  strange  male  with 
whom  she  may  copulate,  it  must  also  be  accepted  that 
the  vagina  of  the  female  becomes  inured  to  the  contact 
of  the  irritating  products  of  morbid  conditions  of  the 
mucous  membrane  higher  up — in  other  words,  be- 
comes tolerant  of  auto-genetic  poisons.  This  same 
tolerance  explains  her  resistance  to  the  disease  when 
brought  to  her  by  contagion.  (3)  Of  the  relatively 
inherent  toughness  of  the  vagina,  as  a consequence  it 
may  serve  as  a vessel  in  which  toxic  materials  ma}^  be 
elaborated  without  becoming  itself  infected  b}'  them. 
This  inherent  resistancy  does  not  extend  to  the  endo- 
metrium, Fallopian  tubes,  and  peritoneum  ; hence  a 
woman  ma}'  have  more  or  less  active  gonorrhoeal  pro- 
cesses in  these  parts,  while  the  vagina  is  apparently 
perfectly  healthy. 

The  importance  of  a knowledge  of  the  direct  and 
remote  results  of  gonorrhoea  in  women,  can  hardly  be 
overestimated,  and  is  but  recentl)’  receiving  its  due 
meed  of  attention.  Foreshadowed  b}^  the  labors  and 
once  ridiculed  theories  of  Noeggerath,  the  researches 
of  modern  operative  gynecologists  are  developing 
most  astonishing  facts  relative  to  the  subject  in  ques- 
tion.* 

It  must  be  remembered  in  this  connection  that 
there  are  two  ways  in  which  the  gonorrhoeal  v'irus  may 
act  in  the  production  of  morbid  conditions  in  women, 
and  this  fact,  unfortunatel}’.  seems  to  have  been  over- 
looked by  Dr.  Noeggerath  and  his  disciples.  These 
investigators  seem  to  believe  that  those  morbid  results 
of  gonorrhoea  which  are  manifested  b\^  diseased  con- 
ditions of  the  uterus.  Fallopian  tubes,  parametrium 
and  ovaries,  are  the  results  of  a primary  imfection 
derived  fi'om  uncleanl}^  intercourse.  This  is  a one- 
sided view  of  the  question,  for,  as  a consequence  of 
various  exciting  causes,  the  pelvic  organs  of  the 
female  may  become  infected  from  various  inflamma- 
tory and  putrefactive  processes  in  her  own  generative 
apparatus — not  necessarily  dependent  upon  antece- 

*The  best  article  that  has  yet  appeared  upon  gonorrhoeal  infec- 
tion in  women  is,  in  mv  opinion,  that  recently  published  by  Wil- 
liam Jap  Sinclair,  of  England. 


GONORRHCEA  [N  WOMEN. 


19 


dent  contagion.  While  willing  to  accept  in  the  main 
the  doctrines  of  Noeggerath  and  his  votaries,  I am 
strenuously  opposed  to  the  idea  that  infection  from 
without  is  the  fans  origo  et  7nali  in  anything  like  the 
majority  of  cases.  Professor  Noeggerath’ s theory 
implies  : 

1.  That  nearly  all  individuals  who  have  at  a more 
or  less  remote  period  contracted  gonorrhoea  and  have 
apparently  been  cured,  are  capable  of  imparting  in- 
fection to  the  female.  Thus  men  who  have  at  some 
time  had  the  disease,  according  to  Noeggerath,  infect 
their  wives  in  the  majority  of  instances. 

2.  That  this  infectiousness  on  the  part  of  the  male, 
is  in  many  instances  latent,  but  may  possibly  become 
perceptible  by  the  occurrence  of  urethritis  of  a greater 
or  less  degree  of  severity,  as  a consequence  of  sexual 
intercourse. 

3.  That  as  a consequence  of  this  latent  condition 
of  gonorrhoea  in  the  male,  there  occurs  a similarly 
latent  infection  of  the  wives  of  those  thus  affected. 

4.  That  the  majority  of  women  who  marry  men 
who  have  at  one  time  or  another  had  gonorrhoea, 
become  sooner  or  later  the  subjects  of  uterine  and 
pelvic  inflammations. 

There  is  something  very  striking  in  these  views, 
especially  if  we  take  into  consideration  the  large  pro- 
portion of  women — particularly  in  large  cities  —who 
have  pelvic  troubles  of  various  kinds.  It  is  certainly 
peculiar  that  matrimony  should  entail  upon  the  female 
so  many  varied,  severe  and  annoying  difficulties  of 
the  sexual  organs.  Faulty  hygiene,  improper  habits 
and  modes'  of  living  with  an  attendant  hereditary 
transmission  of  physical  defects,  in  consideration  with 
sexual  excess,  explain  these  troubles  Lo  a certain  ex- 
tent ; add  to  these  factors  that  of  deliberate  and  vic- 
ious interference  with  nature’s  processes  in  the  per- 
formance of  abortions,  and  we  have  a series  of  all 
sufficient  causes  for  gynic  disease.  It  must  be  remem- 
bered, however,  that  the  disproportion  in  the  frequenc}^ 
of  occurrence  of  gynic  disease  in  city-bred  and  in 
country  women,  is  greater  than  could  be  reasonably 
explained  by  these  various  factors.  Add  the  elements 


20 


GONORRHCEA  IN  WOMEN. 


of  prostitution  and  illicit  intercourse,  the  opportuni- 
ties for  which  are  greater  in  cities,  with  their  attend- 
ant facilities  for  the  generation  and  transmission  of 
infection,  and  the  explanatory  chain  is  complete. 

Strange  as  it  may  appear,  the  more  carefull}’  we 
study  pelvic  diseases  in  women  the  narrower  their 
etiological  field  becomes  and  the  more  frequently 
they  are  found  to  be  dependent  upon  gonorrhoea. 
Thus,  when  freed  from  pathological  and  anatomical 
errors,  pelvic  inflammations  are  found  to  be  depend- 
ent in  the  majority  of  cases,  if  not  all,  upon  tubal 
disease,  and  tubal  disease  is  unquesticnably  almost 
always  due  to  gonorrhoeal  infection. 

With  regard  to  the  frequenc}'  of  gonorrhoea  among 
the  inhabitants  of  cities,  Noeggerath  said  some  }‘ears 
ago,  “ I do  not  know  what  the  state  of  matters  in 
other  cities  is;  I did  not  know  how  w’e  stood  in  New 
York,  until  I questioned  the  husband  of  every  woman 
who  came  under  treatment,  but  I believe  we  ma}’ 
apply  here  the  dictum  of  Ricord  that  800  men  in  1000 
have  had  gonorrhoea.”  He  goes  further  and  sa3’s,  “ I 
believe  that  I do  not  exaggerate  when  I say  that 
gonorrhoea  in  90  per  cent  of  the  cases,  remains 
uncured.  Of  ever}^  hundred  women  who  have  mar- 
ried men  formerly  affected  b^^  gonorrhoea,  hardl}^  ten 
remain  w'ell,  the  others  are  afflicted  b)'  some  of  the 
ailments  which  I have  attempted  to  describe.”* 

Making  due  allowance  for  exaggerations  on  the  part 
of  converts  to  the  doctrines  of  Noeggerath,  it  must 
still  be  admitted  that  the  poison  of  gonorrhoea  may 
produce  any  or  all  of  a series  of  disastrous  results  in 
the  female  pelvic  organs.  Thus  there  ma}'  be  metri- 
tis, endometritis,  salpingitis,  hydro  and  pyosalpinx, 
ovaritis,  parametritis,  pelvic  peritonitis,  menstrual 
disorders  and  sterilit)^  according  to  the  severity  of  the 
process  and  the  character  of  the  structures  affected. 
Although  rare,  vesical,  urethral  and  even  renal  dis- 
ease of  an  inflammatory  character  may  occur  as  in 
the  male. 

It  is  to  be  remembered  that,  as  already  suggested. 


*Morbid  Results  of  Latent  Gonorrhoea  in  the  Female,  1872 


GONORRHCEA  IN  WOMEN. 


21 


these  results  ma}^  occur  as  a consequence  of  infection 
of  the  affected  structures  without  the  contagium  be- 
ing necessarily  hetero-genetic.  The  point  of  depar- 
ture is  certainly  not  the  urethra  of  the  male,  but 
as  far  as  clinical  evidence  and  theoretical  reasoning 
enable  us  to  judge,  must  of  necessity  be  the  genera- 
tive apparatus  of  the  female.  Admitting  this  to  be 
true,  it  is  an  indubitable  fact  that  any  woman  whose 
generative  apparatus  is  capable  of  infecting  any  male 
with  whom  she  may  have  intercourse,  is  also,  under 
favorable  conditions,  capable  of  infecting  any  portion 
of  her  own  generative  tract  which  happens  to  be  suc- 
ceptible  to  the  irritating  effects  of  the  autogenetis 
poison.  Such  infection  may  occur  without  any  excit- 
ing cause,  although  in  perhaps  the  majority  of  in- 
stances some  special  circumstance  or  other  is  neces- 
sary to  the  development  of  infectious  inflammation, 
e.  g.,  we  will  suppose  that  a woman  of  uncleanly 
habits,  easy  virtue  and  debilitated  constitution,  suf- 
fers from  a miscarriage,  as  a consequence  of  which 
her  parturient  canal  is  in  a wounded  condition,  the 
same  poison — which  various  circumstances  of  en- 
vironment have  caused  to  develop  in  her  generative 
apparatus — that  would  develop  urethritis  in  the  male 
may  obviously  produce  in  her  such  inflammatory  con- 
ditions as  severe  metritis,  endometritis,  salpingitis, 
cellulitis,  pelvic  peritonitis,  etc.,  etc.  It  is  admitted 
that  the  male  may  contract  urethritis  from  women 
who  have,  as  far  as  can  be  determined,  no  specific  in- 
flammatory condition  of  the  generative  tract,  but  who 
are  uncleanly  and  are  afflicted  with  ordinary  catarrh- 
al conditions  of  the  mucous  membrane,  which 
catarrhal  conditions  generate  an  acrid  discharge.  Is 
it  not  reasonable  to  suppose  that  when  the  sexual 
organs  of  such  a woman  become  wounded  in  the  pro- 
cess of  parturition,  she  becomes  susceptible  to  the 
local  effects  of  this  same  auto-genetic  poison?  I 
venture  to  assert  that,  leaving  out  of  consideration 
those  cases  of  pelvic  inflammation  due  to  septic  in- 
fection at  the  hands  of  the  accoucheur,  the  majority 
of  cases  of  pelvic  disease  following  labor,  premature 
or  normal,  are  due  to  auto-infection.  There  may  be 


22 


GONORRHCEA  IN  WOMEN. 


absolutely  no  lines  ol  differentiation  to  be  drawn  be- 
tween those  cases  in  which  the  irritant  poison  is  de- 
veloped de  novo  in  the  woman  and  those  in  which  it 
has  been  imparted  to  her  through  uncleanly  inter- 
course. The  results  are  the  same. 

While  it  is  unquestionably  true  that  many  cases  of 
urethritis  in  the  male  remain  infectious  for  some  time 
after  gonorrhoea  is  apparently  cured,  I am  still  of  the 
opinion  that  cases  in  which  the  disease  has  apparently 
been  cured  for  six  months  or  more  are,  in  the  absence 
of  stricture,  non-contagious  ; and  there  are  instances 
in  which  a slight  stickiness  of  the  meatus  still  exists 
in  which  there  are  no  properties  of  contagiousness, 
and  it  is  perfectly  safe  to  advise  the  patient  to  get 
married.  That  extreme  caution  is  necessar}'  in  this 
respect,  I am  willing  to  admit,  and  that  a patient  with 
strictures  should  not  be  allowed  to  marry  should,  in 
my  opinion,  go  without  the  saying.  I have  no  dispo- 
sition in  any  sense  to  antagonize  the  views  of  the 
Noeggerath  school,  but  I must,  nevertheless,  protest 
against  the  illiberality  of  ascribing  the  results  of 
gonorrhoeal  infection  to  direct  contagion  in  all  cases, 
with  a total  disregard  of  the  numerous  morbid  possi- 
bilities of  auto-infection. 

Gonorrhoeal  vaginitis  is  usuall}"  seen  in  comparative!}’ 
cleanly  and  healthy  women  who  have  become  infected 
with  the  products  of  virulent  urethritis  in  the  male.  The 
younger  and  more  cleanly  the  patient,  the  more  viru- 
lent the  vaginitis.  It  is  a striking  fact  that  vaginitis 
in  young  children  is  apt  to  be  very  severe.  I have 
seen  but  two  instances  of  virulent  vaginitis  from  con 
tagion  occurring  in  young  female  children — one  in  a 
child  of  ten  years  and  the  other  in  a child  of  four — 
both  of  which  I was  able  to  trace  to  their  source. 
Rarely  indeed,  is  so  high  a grade  of  inflammation  seen 
in  the  adult  female. 

In  connection  with  the  possible  infectiousness  of 
chronic  urethral  disease  in  the  male.  I will  again  call 
your  attention  to  the  possibility  of  the  transformation 
of  the  virulent  process  in  such  a manner  that,  although 
no  longer  capable  of  exciting  virulent  inflammation, 
there  is  formed  at  the  site  of  the  urethral  disease 


GONORRHCEA  IN  WOMEN. 


23 


toxic  compounds  ot  ptomaines  which  are  capable  of 
exciting  in  the  female  gynic  disease  of  various  kinds. 
The  possibility  of  gonorrhoeal  processes  in  the  female 
becoming  latent  is  of  very  great  importance  with  ref- 
erence to  the  transmission  of  the  disease  to  the  male. 
For  example,  supposing  that  a woman  has  been  at 
one  time  or  another  affected  with  gonorrhoea,  which 
has  become  localized  in  the  Fallopian  tubes;  it  is 
probable  that  under  sexual  excitement  or  during  men- 
struation, a small  quantity  of  the  retained  poison  may 
be  extruded  into  the  uterus  and  mingling  with  the 
secretions  of  that  organ  and  the  vagina,  eventually 
come  in  contact  with  the  urethra  of  the  male,  exciting 
therein  virulent  urethritis.  Her  own  mucous  mem- 
branes are  no  longer  susceptible  to  the  irritant  action 
of  the  virus  because  of  their  susceptibility  having  been 
exhausted  by  the  primary  infection.  Upon  examina- 
tion such  a woman  would  present  no  trace  of  virulent 
disease,  although  she  would  invariably  be  found  to 
have  been  more  or  less  pronounced  uterine  difficulty. 
A parallel  case  might  occur  in  which  the  primary 
source  of  the  disease  was  not  from  infection  without. 
Supposing  for  example,  as  a consequence  of  sexual 
excess,  filth,  simple  uterine  inflammation,  intemper- 
ance, cachexia  and  so  on,  a woman  should  develop 
the  irritating  poison  of  gonorrhoea  ; her  own  mucous 
membranes  becoming  gradually  involved,  the  process 
finally  disappears  in  other  situations  but  localizes 
itself  in  the  Fallopian  tube  and  endometrium;  as  a 
consequence  of  some  of  the  exciting  causes  heretofore 
mentioned,  the  pent-up  poison  is  discharged  into  the 
vagina  and  causes  urethritis  with  the  first  unlucky 
male  who  has  intercourse  with  her.  Upon  examina- 
tion she  too  presents  no  evidences  of  disease  other 
than  ordinary  endometritis,  and  perhaps  even  this  in 
a mild  degree.  To  go  a little  further  in  describing 
the  morbid  possibilities  of  this  latent  gonorrhoeal  pro- 
cess of  the  Fallopian  tubes,  we  will  suppose  that  as  a 
consequence  of  sexual  excitement,  traumatism,  partu- 
rition, violent  exercise,  etc.,  a small  quantity  of  this 
poison  is  discharged  into  the  peritoneal  cavity  ; obvi- 
ously there  would  occur  as  a consequence,  localized 


24 


GONORRHCEA  TN  WOMEN. 


peritonitis  with  possible  pelvic  abscess.  It  is  a strik- 
ing fact  that  these  latent  gonorrhceal  processes  proba- 
bly on  account  of  some  transformation  of  the  virus  do 
not  usually  produce  general  peritonitis.  This  disease 
may,  however,  occur  as  a consequence  of  gonorrhoea, 
but  almost  invariably  as  a direct  result  of  rupture  of 
a pelvic  abscess  which  is  in  itself  due  to  gonorrhoeal 
infection,  or  of  an  extension  of  virulent  vaginitis, 
endometritis  and  salpingitis. 

It  is  probable  that  gonorrhoeal  inflammation  of  a 
chronic  character  may  affect  the  glandulse  Nabothi 
and  Bartholini ; under  such  circumstances  the  woman 
might  go  on  transmitting  contagion  of  urethritis  for 
an  indefinite  period  of  time  after  all  visible  evidences 
of  virulent  vaginitis  has  disappeared,  this  being 
another  of  those  puzzling  cases  in  which  urethritis  is 
contracted  from  an  apparently  healthy  woman. 

The  urethra  of  the  female  is  very  rarely  involved  in 
virulent  inflammation,  this  being  due  to  its  protected 
situation.  The  vulva,  or,  at  least,  the  more  external 
portions  of  it,  not  being  particularly  susceptible  to  the 
products  of  virulent  inflammation,  the  process  does 
not  readily  extend  itself  to  the  meatus;  it  never  does 
so,  excepting  in  cases  of  virulent  vaginitis  due  to  con- 
tagion. Whenever  in  the  course  of  a vaginitis,  ure 
thritis  develops  with  or  without  inflammation  of  the 
bladder  it  is prima  facie  evidence  that  the  disease  was 
primarily  due  to  infection.  This  fact  is  due  not  to 
any  peculiar  propert}'  of  the  virus,  but  to  the  fact  that 
the  urethra  is  never  involved,  excepting  in  the  more 
violent  cases  of  inflammation,  and  these  more  violent 
cases  of  inflammation  are  invariabl}^  due  in  the  female 
to  venereal  contagion. 

It  has  been  claimed  by  Martineau  that  the  reaction 
of  the  secretion  of  vaginitis  determines  the  diagnosis 
of  its  specific  or  non-specific  character.  He  claims 
that  the  pus  of  specific  vaginitis  is  always  acid,  while 
in  the  simple  variety  it  is  alkaline.  It  is  to  be  hoped 
that  this  fallacious  test  may  not  be  depended  upon 
for  the  differential  diagnosis,  inasmuch  as  up  to  the 
present  time  no  other  observer  has  been  able  to  con- 
firm the  opinion  of  Martineau. 


25 


H\"PER  TROPHY  AND  HYPERPLASIA  CONSE- 
QUENT UPON  LESIONS  OF  THE 
GENITALIA. 

Read  before  tbe  Chicago  Academy  of  Medicine 

In  presenting  the  subject  of  hypertrophy  and  hy- 
perplasia incidental  to  lesions  of  the  genitals,  I shall 
not  attempt  to  edify  you  with  a wearisome  resume 
of  all  this  work  that  has  been  done  in  this  field. 
Some  of  the  work  has  been  composed  of  such  il- 
logical reasoning  and  so  many  inaccurate  observa- 
;ions,  illy  assorted  and  crudely  digested  facts,  that  it 
constitutes  a mass  of  pathological  and  clinical  inac- 
curacies, useful,  perhaps,  for  comparison  and  critic- 
ism, but  absolutely  useless  to  a body  of  clinicians  of 
this  day  and  generation.  As  far  as  the  historical  in- 
terest surrounding  the  pathological  errors  of  the 
past  is  concerned,  the  classical  contribution  of  R. 
W.  Taylor  has  done  the  subject  full  justice.  It  has 
been  mainly  through  the  efforts  of  this  author  that 
the  fanciful  and  absurd  pathological  conceptions  of 
Huguier,  published  only  a little  more  than  four  de- 
cades ago,  have  been  dispelled  and  the  errors  of 
those  who  have  followed  Huguier — like  sheep  fol- 
lowing the  bell-wether  over  the  fence, — illumined  by 
the  light  of  modern  pathology.  It  was  an  unfortu- 
nate thing  for  pathology,  that  the  essay  of  Huguier 
on  esthioraene  or  lupus  of  the  vmlva^  was  ever  pub- 
lished, for  it  was  so  generally  accepted  as  law  and 
gospel  as  to  have  been  regarded  as  a classic  until 
comparatively  recent  years. 

Great  men  fell  into  the  pathological  trap  set  for 
them  by  Huguier  and  his  contemporaries  quite  as 

IP.  C.  Huguier,  Memoire  sur  I’esthiomene  ou  dartre  rongeante  de  la  re- 
gion vulvo-anale,  Paris  1849. 


26 


readily  as  did  the  rank  and  file  of  the  profession. 
The  fact  that  the  late  Isaac  E.  Taylor  adopted  and 
taught  the  views  of  Huguier  is  very  significant  in 
this  connection.  2 

R.  W.  Taylor  has  well  stated  the  case  when  he 
says,  regarding  Huguier’s  brochure:  “ It  is  very 

probable  that  most  of  his  cases  were  those  of  old 
syphilis,  their  etiology  was  wholly  unexplored  and 
the  clinical  history  of  the  fanciful  disease  wa.<=  given 
in  the  most  positive  manner,  though  based  onlv  upon 
crude  and  far-reacbing  assumptions.  It  seems 
wonderful  that  his  lucubrations  were  entertained  bv 
educated  men.  Yet  even  to-day,  though  there  are 
a few  dissenters,  there  are  very  many  believers  in  a 
morbid  entity  which  they  call  lupus  or  the  esthio- 
mene  of  Huguier.  I do  not  know  in  all  medical 
history  of  an  essay  founded  on  gross  error  and  pure 
assumption  which  had  such  influence  for  so  many 
years  in  moulding  medical  opinion,  not  only  in 
France,  but  in  other  countries.”® 

The  fact  that  the  subject  is  still  replete  with  error, 
or  even  a terra  incognita  to  the  majority  of  general 
practioners,  is  my  excuse  for  bringing  it  to  the  at- 
tention of  the  Academy  this  evening.  I do  not  hesi- 
tate to  say,  that  in  my  opinion  many  specialists  fail 
to  grasp  the  principles  of  pathogenesis  underlying 
the  conditions  which  I propose  to  consider.  In  pre- 
senting these  principles,  I may  be  here  and  there 
somewhat  heretical,  but  I trust  that  my  facts  may 
be  none  the  less  consistent. 

Nearly,  if  not  all  the  special  work  that  has  been 
done  in  the  study  of  hyperplasia,  chronic  ulceration 
and  hypertrophy  of  the  genitals  has  been  devoted 

2Lupus  or  esthiomene  of  the  vulvo-anal  region.  Trans.  Am.  Gvn.  Soc- 
1882. 

3R.  W.  Taylor.  Chronic  infiltration,  inflammation  and  nlceration.  of 
the  external  genitals  of  woman.  N.  Y.  Medical  .lournal,  Jaumiry  4th,  1890. 


27 


to  the  study  of  these  lesions  in  the  female.  It  is  my 
purpose  to  demonstrate  that  the  lines  of  pathological 
parallelism  between  the  male  and  female  are  closer 
than  is  generally  supposed,  as  far  as  the  lesions  un- 
der consideration  are  concerned.  The  difference  in 
degree  and  frequency  is  admited,  but  even  this  is 
due  to  certain  local  anatomical  and  physiological 
peculiarities,  the  result  of  which  is  by  no  means  con- 
ducive to  the  well-being  of  the  female. 

Beginning  with  lesions  observed  in  women,  it  is 
safe  to  say  that  Taylor’s  conclusions,  as  based  upon 
hundreds  of  carefully  studied  and  well  observed 
cases,  are  not  only  comprehensive  but  with  few,  if 
any,  qualifications  absolutely  correct.  I therefore 
take  the  liberty  of  presenting  them  verbatim. 

“I.  A large  and  perhaps  the  greater  number  of 
chronic  deforming  vulvar  lesions  are  due  to  simple 
hyperplasia  of  the  tissues  induced  by  irritating  causes, 
inflammation  and  traumatisms. 

“ 2.  Chronic  chancroid  is  a cause  in  a certain 
proportion  of  cases. 

“ 3.  Man}'  cases  are  due  to  essential  and  specific 
syphilitic  infiltration. 

“ 4.  Other  cases  are  caused  by  the  hard  oedema 
which  often  complicates  and  surrounds  the  initial 
sclerosis  and  perhaps  gummatous  inriltration. 

“ 5.  Many  cases  are  due  to  simple  hyperplasia  in 
old  syphilitic  subjects  who  suffer  from  the  chronic 
ulcerations  of  the  vulva  long  after  all  specific  lesions 
have  departed. 

“ 6.  Some  cases,  also  in  old  syphilitics,  are  due 
to  simple  hyperplasia  without  the  existence  of  any 
concomitant  ulcerative  or  infiltrative  process  and 
seem  to  be  caused  by  conditions  which  usually  in  healthy 
persons  only  result  in  vulvar  injianimation. 

Regarding  the  influence  of  .simple  irritation  in  the 


28 


production  of  defoi  ming  vulvar  lesions,  Ta\'lor  quite 
naturally  takes  up  for  consideration,  vegetations, 
caruncles,  and  simple  hyperplastic  tumors  of  the 
vulva,  and  has  traced  the  successive  gradations  of 
pathological  development  from  these  minor  growths 
to  those  enormous  tumors  occasionally  seen,  which 
are  productive  of  so  much  deformity  and  mechanical 
discomfort.  In  the  light  of  our  clinical  knowledge 
of  the  smaller  growths  which  indicate  the  point  of 
departure  on  the  road  to  exti'eme  degrees  of  hvper- 
trophy  and  h3.-perplasia,  it  is  not  easy  to  understand 
how  local  conditions  alone  as  believed  by  Taylor  can 
cause  tbe  development  of  such  neoplasms.  When  we 
are  confronted  by  the  more  formidable  varieties  of 
lesion,  the  query  becomes  still  more  pertinent:  Are 
local  circumstances  of  environment  alone  responsible 
for  this  condition?  Is  there  not  required  some  in- 
herent predisposition?  If  not,  wh^-  do  not  all  pa- 
tients with  similar  or  worse  local  environment,  pres- 
ent similar  lesions? 

How  like  the  vegetable  fungi  is  the  development 
and  even  the  phj'Sical  appearance  of  the  so-called 
venereal  vegetations.  Heat,  miosture,  filth,  depriva- 
tion of  light  and  air,  and  more  or  le  ss  continuous 
irritation  are  the  essential  conditions  for  the  develop- 
ment of  the  mush-room-like  genital  vegetations.  But 
whence  comes  the  peculiar  influence  which  develops 
them  in  one  dirty  patient  rather  than  in  any  one  of  a 
dozen  others?  Why  is  it  that  a woman  ma}' de- 
velop from  a comparatively  slightly  irritating  dis- 
charge during  pregnancy-mayhap  without  venereal 
infection — an  enormous  mass  of  vegetations,  while 
much  lesscleanly^  and  perhaps  gonorrhceally  infected 
women  with  profuse  and  acrid  discharges  escape? 
Why  will  vegetations  springing  up  in  several  women, 
under  circumstances  apparentlv  identical,  take  such 


29 


a dissimilar  course;  in  the  one,  a few  small  and  in^ 
significant  growths  appearing,  while  in  the  other  an 
enormous  mass  develops  in  an  incredibly  short  time? 
It  certainh'^  must  be  admitted  that  the  discharges  of 
a pregnant  woman  have  no  specific  property  per  se, 
3^et  it  is  during  pregnancy,  especially,  that  vulvar 
vegetations  flourish  and  wax  luxuriant.  This,  in  face 
of  the  fact  that  women  wfith  serious  uterine  and 
vaginal  discharges  do  not  often  become  pregnant. 
If,  then,  there  are  no  evidences  of  post-pregnant 
venereal  infection  we  must  necessarily  admit  that  the 
presence  of  “ venereal  ” vegetations  in  any  given 
case  is  not  a criterion  of  the  acridity  or  specificity  of 
the  discharge. 

Heat,  moisture  and  darkness  favor  the  devolp- 
ment  of  vegetable  fungi,  but  these  conditions  do  not 
develop  fungi.  The  seed  must  be  sown  or  pre-exist 
in  the  soil,  and  the  soil  itself  must  be  of  proper 
quality.  We  must  either  admit  a special  bacterium 
in  genital  vegetations,  or  else  advance  something  in 
the  way  of  individual  susceptibility  of  tissue  and 
tendancy  to  connective  tissue  proliferation,  to  explain 
the  occurrence  of  these  lesions  in  so  small  a pro- 
portion of  cases  of  like  conditions.  Again,  primary 
predisposition  alone  may  not  be  a sufficient  explana- 
tion. We  must  still  explain  the  development  of 
vegetations,  caruncles,  etc.,  in  pregnant  women,  in 
whom  the  local  conditions  are  no  worse  than  for 
months  or  even  years  before  pregnancy  occurred, 
yet  in  whom  vegetations  develop  only  after  preg- 
nancy, and  almost  immediately  thereafter. 

It  is  easy  to  understand  how  one  may  be  led  to 
believe  that  local  causes  are  all  important  in  the 
causation  of  chronic  deformities  of  the  vulvo-vag- 
inal  and  vulyo-anal  region  from  observation  of 
broken  down  prostitutes,  but  even  these  conditions  oc- 
casionally occur  in  comparatively  young  women, 


30 


and  persist  and  prove  fatal  despite  removal  of 
sources  of  irritation  and  best  of  treatment. 

In  seeking  the  cause  of  perverted  tissue-growth, 
we  must  consider  not  only  the  excitant,  be  it  bacterial, 
chemical  or  traumatic,  that  sets  the  process  of  patho- 
logial  tissue-building  in  motion,  but  the  inherent 
physiological  power  of  development — through  the 
medium  of  which  all  perversions  of  tissue  growth 
must  necessarily  act.  Independently  of  the  poten- 
tial power  of  proliferation  and  development  pos- 
sessed by  the  cell  per  se,  there  exists,  to  put  it  meta- 
phorically, a master  architect  and  general  superin- 
tendant  of  construction  somewhere  in  the  nervous 
centers,  exactly  where  we  do  not  know,  but  in  close 
relation  at  least  to  the  great  s^’mpathetic  system. 
The  result  of  this  superintendency  we  recognize  as 
the  trophic  or  nutritive  function  of  the  nervous  sys- 
tem. To  consider  whether  there  be  a special 
trophic  system  or  simply  a specialization  of  function 
on  the  part  of  the  sympathetic  ganglia  as  a whole, 
which  seems  most  probable,  would  be  begging  the 
question.  As  in  the  building  of  a house  faulty  con- 
struction may  be  in  the  direction  of  poor  materials, 
lazy  or  incompetent  workmen,  or  poor  architecture 
or  superintendency,  so  in  tissue  building  we  may 
have  fanltv  pabulum,  excessive  zeal,  or  laziness  and 
incompetency  of  cells,  and  faulty  architecture  or 
superintendency. 

Now,  it  is  my  humble  opinion  that  we  are  drifting 
away  from  certain  sound  principles  of  medical  phil- 
osophy, abstract,  perhaps,  but  still  practical  and 
logical,  into  too  materialistic  a view  of  pathological- 
states,  the  focal  point  of  which  is  the  germ  and  its 
products;  or,  to  put  it  more  succinctly,  a view  which 
is  chiefly  founded  on  the  local  and  tangible  influences 
w'hich  tend  to  excite  pathological  conditions.  The 


Fig.  1.  Showing  great  hyperplasia  of  the  clitoris  and 
nymphoe.  (After  Taylor.) 

influence  of  the  nervous  system,  firstly  in  normal, 
and  secondl}^  in  abnormal  conditions  of  tissue-build- 
ing, is  forgotten. 

x\s  regards  the  various  forms  of  genital  hyper- 
plasia and  chronic  induration,  the  microscope  shovv- 
them  to  be  composed  of  simple  overgrowth  of  con- 
nective tissue  with  a varying  amount  of  new  vascu- 


32 


lar  tissue.  It  is  hardly  necessary  to  call  attention  to 
the  fact  that  we  have  here  an  excellent  illustration 
of  exaggerated  repair,  and  that  behind  it  we  have 
the  normal  trophic  impulse.  Now,  I cannot  be  con- 
vinced that  this  overgrowth  is  due  to  local  causes 
alone;  there  is  too  great  a disparity  between  the 
number  of  those  in  whom  the  supposed  local  causes 
exist  and  those  in  whom  these  conditions  actually 
develop.  1 believe,  in  brief,  that  the  difference  be- 
tween those  who  do  and  those  who  do  not  develop 
these  conditions  under  like  circumstances  lies  in  the 
direction  of  the  nervous  system.  In  other  words,  I 
believe  that  the  essential  cause  is  a tropho-neurosis. 
We  have  not  far  to  look  for  analogies.  Ilav'e  we  as 
yet  received  any  saiisfactorc^  explanation  of  Keloid? 
And  where  can  we  find  a prettier  illustration  of 
tropho-neurotic  disturbances  than  in  herpes  zoster 
and  its  congeners,  more  particularly  herpes  progeni- 
talis?  If  the  illustration  of  herpes  progenitalis  be 
not  accepted,  I desire  to  call  attention  to  menstrual 
herpes  and  the  herpes  of  pregnane}'.  These  latter 
conditions  may  be  associated  in  your  minds  with  the 
menstrual  and  utero-vaginal  discharges;  I have, 
however,  observed  menstrual  herpes  occurring 
regularly  just  before  and  during  menstruation,  and 
in  pregnant  women  who  have  no  discharges  of  any 
kind.  I have  met  with  two  cases  where  the  first 
and  pathognomonic  sign  of  pregnancy  is  herpes  pro- 
genitalis, recurring  in  one  case  precisely  at  the  usual 
menstrual  epoch.*  The  serious  nutritive  results  of 
herpes,  or  rather  the  nutritive  perversion  of  which 
herpes  is  but  a symptom,  are  well  known.  Those 
who  are  engaged  in  ophthalmic  practice  will  at  once 
recall  the  disastrous  effects  of  herpes  frontalis  seu 
orbicularis  when  the  eye  is  invaded.  As  a further 

*I  have  expatiated  more  fu  ly  upon  the  subject  of  herpes  progenitalis 
in  a paper  read  before  the  North  Texas  State  Jled.  . ssoc..  Dec.  15, 1890. 


33 


illustration  of  a tropho-neurosis,  I will  call  attention 
to  Raynaud’s  disease.  The  cause  of  the  tropho- 
neurosis may  consist  of  a congenitally  unstable  equili- 
brium of  trophic  innervation,  or  of  an  acquired 
perversion  due  to  constitutional  causes  or  to  local 
influences  of  a reflex  character.  There  may  or  may 
not  be  a germ  factor  in  the  case.  Obviously,  when 
once  the  perverted  tissue-building  has  begun,  we 
may  have  at  any  time  in  the  course  of  the  affection 
intercurrent  ulceration,  suppuration  or  necrosis,  de- 
pendent on  the  degree  of  tropho-neurotic  disturb- 
ance, and  the  degree  and  kind  of  local  irritation  or 
infection  present.  It  will  be  observed  that  I give 
due  credit  to  purely  local  conditions. 

In  classes  2,  4 and  5 in  Taylor’s  conclusions  we 
have  lesions  which  are,  in  my  opinion,  still  more 
closely  associated  with  tropho-neurotic  disturbances 
than  are  the  simpler  genital  lesions,  and  differing 
from  the  latter  in  the  fact  that  there  is  a tendency 
to  tissue  necrosis  which  results  in  more  or  less  ex- 
tensive ulceration,  and  oftentimes  sloughing.  As 
far  as  chancroid  is  concerned,  there  is,  even  in  the 
primary  chancroidal  infection,  no  tendency  per  se 
to  extensive  destruction  of  tissue;  the  process  is 
self-limited.  It  is  probable  that  phagedtena,  slough- 
ing, and  serpiginous  ulceration  of  a chronic  charac- 
ter are  not  due  to  the  primary  infection,  but  to  local 
or  constitutional  conditions  predisposing  to  tissue 
destruction  or  to  secondarv  infections.  After  eli- 
minating  all  local  causes  of  severity  or  malignancy, 
there  still  remains  a certain  proportion  in  which  pro- 
found destruction  of  tissue  results.  In  some  of  these 
a true  cachexia  exists  as  explanatory  of  the  severity 
of  the  process,  syphilis  being  very  apt  to  lead  to  a 
severe  type  of  chancroid.  In  others,  however, 
healthy,  robust  patients  will  be  attacked  by  phage- 


34 


dsena  and  perhaps  serpiginous  ulceration,  while 
other  patients  of  apparently  less  robust  physique  will 
contract  simple  chancroid  from  the  same  source  of 
infection.  This  I have  known  to  occur  even  among 
cleanly  patients  in  private  practice.  The  key-note 
to  the  situation  I believe  to  be  a tropho-neurosis  in 
the  one  class,  which  does  not  exist  in  the  other.  If 
this  be  true  of  acute  chancroid,  how  much  more 
powerful  must  the  element  of  tropho-neurosis  be  in 
the  socalled  chronic  chancroid,  a condition  which 
should  not  be  termed  chancroid  at  all,  and  which 
consists  of  chronic  post-chancroidal  ulceration,  the 
starting  point  of  which  is  a virulent  infection  to  be 
sure,  but  the  perpetuation  of  which  depends  upon 
socalled  idiosyncrasy.  Would  not  the  term  tropho- 
neurosis, theoretical  though  it  ma}^  appear,  be  a wel- 
come substitute  for  idiosyncrasy  in  these  cases?  In 
the  battle  between  the  cells  of  the  infected  area  and 
the  poison  of  the  infection,  the  cells  conquer  after  a 
short  period;  the  power  of  the  virus  is  exhausted 
and  simple  ulceration  takes  the  place  of  a virulent 
process;  in  other  words,  the  product  of  the  evolu- 
tion under  the  modifying  influence  of  the  cells  of  the 
affected  part.  This,  under  normal  circumstances 
and  in  the  majority  of  individuals.  Have  we  noth- 
ing better  than  the  term  “ idiosyncrasy  ” to  account 
for  the  cells  giving  up  the  fight  in  some  less  fortun- 
ate patients? 

The  relation  of  s}fphilis  to  h5’pertrophic  and  ul- 
cerative chronic  lesions  of  the  female  genitalia  is,  in 
mv  opinion,  of  the  utmost  importance.  Dr.  Hyde 
has  dwelt  with  especial  emphasis  on  the  intimate 
association  of  syphilis  with  these  lesions.*  Dr. 
Taylor  takes  exception  to  the  etiological  prominence 
accorded  syphilis  by  Dr.  Hyde,  but  it  seems  certain 


* Jouru.  Cutaneous  and  Venereal  Dis. 


35 


that  the  conclusions  of  the  latter  are  sound  as  far  as 
his  own  cases  are  concerned.  Taylor’s  word  of 
caution  is,  however,  timely,  as  it  is  quite  common 
for  the  practitioner  to  attribute  every  lesion  of  the 
genitalia,  whether  simple  or  severe,  to  syphilis,  if  a 
history  of  that  disease  be  elicited,  no  matter  how 
remote  the  infection  may  have  been,  Leaving  out 
of  consideration  the  essential  and  specific  S}'philo- 
mata,  there  are  certain  cases,  and  these  are  by  no 
means  a minority,  in  which  the  relation  of  the  syph- 
ilis is  indirect,  i.  e.,  we  have  processes  resulting 
from  simple  irritation,  traumatism  or  chancroidal 
infection,  upon  a syphilitic  foundation  on  the  one 
hand  or  a tropho-neurotic  foundation  produced  by 
syphilis  on  the  other.  As  an  additional  factor,  al- 
coholism is  apt  to  be  quite  prominent.  It  has  been 
my  fortune  to  see  a number  of  cases  of  chronic  ul- 
cerative vulvar  lesions,  and  it  has  so  happened  that, 
as  far  as  I can  recall  the  cases,  they  have  all  been 
patients  who  had  passed  through  a more  or  less 
severe  course  of  syphilis.  As  most  of  the  cases  I 
have  seen  have  been  hospital  patients,  and  most  of 
the  old  timers  seen  in  hospital  practice  are  syphilitic, 
this  may  not  count  for  much,  but  it  is  worthy  of 
note. 

Another  point  which  is  worthy  of  consideration  is 
til  at  these  cases  are  usually  dosed  with  mercury  at 
varying  intervals  and  in  varying  amounts.  I have 
seen  many  cases  of  chronic  ulcerative  processes  not 
only  about  the  genitalia,  but  elsewhere,  that  have 
been  made  worse  by,  if  indeed  their  chronicity  was 
not  dependent  upon,  the  abuse  of  this  drug,  which 
brings  up  the  practical  point  that  in  these  cases  of 
chronic  ulceration  and  hyperplasia  of  the  female 
genitals,  we  must  be  careful  not  to  treat  the  syphilis 
too  vigorously,  even  if  a clear  history  of  that  disease 


36 


exists;  on  the  contrary,  we  must  treat  the  patient 
and  her  ulcerative  process  rather  than  a constitutinal 
infection  which  as  an  entity  may  no  longer  exist. 

I have  been  led  to  regard  the  severe  ulcerative 
and  hyperplastic  affections  of  the  genitalia  coming 
on  at  a late  period  in  syphilitic  patients  in  the  same 
light  as  other  sequelar  lesions.  Their  true  character 
I believe  to  be  tropho-neurotic.  I presented  this 
view  of  the  late  lesions  of  syphilis  in  extenso  in  a 
paper  before  the  Southern  Surgical  and  Gynaecol- 
ogical Association,  in  1889,  a copy  of  which  I re- 
cently sent  to  each  member  of  this  Academy.  Time 
will  not  permit  me  to  expatiate  upon  this  subject 
this  evening. 

The  source  of  tropho-neurosis  in  syphilis  is  rather 
complex  and  can  be  arranged  in  several  factors. 
First,  The  effect  of  the  syphilitic  infection  on  the 
nervous  system  during  the  active  period.  This  gives 
rise  to  tropho-neurotic  disturbances  both  immediate 
and  remote.  Second,  the  effect  of  mercury,  either 
from  special  intolerance  or  excessive  and  injudicious 
administration.  Third,  Alcoholism.  Fourth,  Vicious 
environment,  with  all  that  it  implies.  Fifth,  Mal- 
nutrition from  privation.  Underlying  all,  may  be  a 
special  fault  of  nervous  structure  with  resultant  in- 
stability of  nutritive  equilibrium  under  all  forms  of 
pathogenesis. 

Does  not  this  view  of  the  etiology  of  the  class  of 
genital  lesions  under  consideration  explain  the  le.sions 
described  in  Taylor’s  sixth  class,  of  old  syphilitics,  in 
which  simple  hyperplasia  “ seems  to  be  -produced  by 
conditions  which  usually  in  healthy  persons  only  result 
inJiammationT'’  If  so,  we  have  only  to  consider  that 
the  supervention  of  ulceration  and  infiltration  depends 
upon  the  degree  of  the  tropho-neurotic  disturbance, 
and  we  can  apply  the  same  explanation  to  several 


37 


Fig.  2.  Showing  great  destruction  of  hypertrophied  vulva 
and  perinaeum  in  an  old  syphilitic.  (After  Taylor.) 

of  the  other  classes  of  these  peculiar  lesions.  Aside 
from  the  tropho-neurotic  element  in  the  causal  influ- 
ence of  syphilis  upon  the  development  of  chronic 
deforming  vulvar  lesions,  there  is  a special  effect 
which  may  result  from  the  primary  lesion  which 
may  be  developed  at  either  an  early  or  later  period. 
This  special  effect  is  included  by  Taylor  under  the 
head  of  “cases  caused  by  the  hard  redema  which 
often  complicates  and  surrounds  the  initial  selerosis 


38 


and  perhaps  gummatous  infiltration.”  This  indur- 
ating oedema  is  an  important  element  not  onl}"  in 
syphilitic  cases^  but  may  be  a factor  even  in  non- 
syphilitic lesions  in  subjects  who  have  previously 
suffered  from  s}’philis.  Taylor  lays  especial  stress 
upon  its  occurrence  in  the  primary  stage  of  sj'philis, 
and  states  that  it  is  the  sole  appanage  of  syphilis. 
This  I believe  to  be  true.  As  Taylor  further  shows, 
and  as  I have  several  times  observed,  cases  occur  in 
which  a chancroid,  or  simple  inflammation,  mav  set 
up  this  peculiar  condition  months  after  the  primary 
lesion  has  disappeared.  Thus,  I have  seen  one  case 
in  which  indurating  oedema  followed  a chancroid 
nearly  a year  after  syphilitic  infection.  I am  inclined 
to  believe  that  some  of  the  so-called  chronic  chan- 
croids owe  their  chronicity  to  the  fact  that  the  in- 
fection has  occurred  upon  a syphilized  base.  The 
explanation  is  not  difficult.  The  immediate  damage 
to  the  multitudinous  capillary  lymphatic  supplv  of 
these  parts  by  the  primary  lesion  is  well  recognized. 
That  this  damage  may  be  permanent  is  not  to  be 
denied.  With  looseness  of  structure,  obstructed 
lymphatic  drainage,  dependent  position  and  more  or 
less  constant  irritation,  traumatic  and  chemical,  it  is 
by  no  means  surprising  that  oedema  should  finally 
merge  into  connective  tissue  h}’perplasia  and  fii  ni 
induration.  That  slight  causes  produce  oedema  of 
the  genitals,  primarily,  is  known  b}'  eveiy  one  whose 
experience  ranges  over  even  a dozen  or  so  of  cases 
of  venereal  lesions  in  male  or  female. 

It  would  be  a work  of  supererogation  for  me  to 
attempt  a minute  description  of  the  peculiar  indur- 
ating oedema  of  S3"philis.  Taylor’s  monograph  is 
a classic  on  this  subject.  The  point  which  I desire 
to  make  in  connection  with  this  form  of  lesion  is  that 
while  later  on  the  element  of  tropho-neurosis  ma}- 


39 


be  superimposed,  or  may  even  exist  primarily,  the 
chief  factor  in  the  condition  is  of  a mechanical  char- 
acter and  relates  to  the  lymphatic  vessels  and  glands. 
Taylor  dwells  in  this  connection,  on  the  active  in- 
fluence of  the  syphilitic  diathesis  in  cases  of  late  in- 
durating oedema  excited  by  traumatism,  and  shows 
the  enormous  hypertrophy  of  the  vulvar  tissues  inci- 
dental to  this  peculiar  oedema.  The  term  diathesis 
is  in  this  connection  a little  obscure.  We  should 
have  some  explanation  of  a local  character,  of  the 
peculiar  results  of  trauma  and  local  irritation  in  a 
syphilized  as  compared  with  a non-syphilized 
patient.  Is  not  the  keynote  of  the  pathological  sit- 
uation sounded  by  Taylor  in  the  remark  that  “ syph- 
ilitic inguinal  adenopathy  is  obesrved  as  a rule  in 
these  cases  ?”  The  greater  degree  of  lymphatic 
involvement  in  these  cases  as  compared  with  ordi- 
nary syphilitics  in  the  later  periods  of  the  disease,  is 
to  me  an  all  sufficient  explanation  of  indurating 
oedema.  With  depots  clogged  a nd  roads  obstructed 
it  is  not  remarkable  that  pathological  goods  should 
accumulate  in  the  factory,  i.  e.,  the  genital  lesion 
and  its  immediate  environment.  The  possible  irri- 
tating effects  of  pathogenic  organisms  must  of 
course  be  considered  in  connection  with  the  deter- 
mination of  the  disease,  and  especiallv  with  its  per- 
petuation if  ulceration  exists. 

The  analogy  between  the  male  and  female  types 
of  chronic  deforming  and  ulcerative  chronic  lesions 
of  the  genitalia  is  especially  marked  in  cases  of  in- 
durating oedema.  That  this  may  be  extensive  is 
shown  by  a case  reported  by  Sturgis,  a reproduc- 
tion of  which  I will  later  exhibit.  * I have  seen  a 
number  of  less  marked  cases  of  a similar  character, 
and  while  I have  seen  a few  in  which  indurating 

* Journal  Cutan  and  Veil.  Dis. 


40 


oedema  followed  a concealed  chancroid  in  , which 
there  was  no  history  of  syphilis  and  no  subsequent 
symptoms  of  the  desease,  it  has  been  m3'  fortune  .to 
obeerv'e  that  in  nearl}'^  all  cases  there  has  been  ante- 
cedent syphilitic  infection,  or  the  oedema  has  been 
directl}^  dependent  on  a chancre  or  a mixed  sore. 
I am  inclined  to  believe  that  while  chronic  ulcera- 
tion is  less  often  seen  in  the  male,  the  comparative 
infrequency  is  due  to  local  anatomical  and  physio- 
logical peculiarities,  and  the  relatively'  greater  facili- 
ty of  management  of  such  conditions  in  the  male. 
Many  cases  of  condy'lomata,  gummy  ulcer  and  re- 
current induration  in  the  male  might  be  transformed 
into  chronic  deforming  lesions  similar  to  those  seen 
in  the  female,  if  local  environment  were  favorable. 

That  the  lines  of  pathological  parallelism  are  some- 
times quite  closeiy'^  drawn  was  shown  by"  two  very 
interesting  cases  observed  during  my'  term  of  ser- 
vice at  tbe  New  York  Charity  Hospital.  One  of 
these  was  a young  woman  with  so  called  lupoid  of 
the  vulva  in  whom  the  ulcerative  hyperplastic  pro- 
cess involved  the  entire  vulva,  the  glands  of  the 
groin,  and  femoral  regions  in  one  continuous  hyper- 
plastic sluggish  mass  bathed  in  scanty  ichorous  pus. 
The  condition  was  painless  but  the  cachexia  pro- 
found. This  case  proved  resistant  to  treatment  and 
finally  died  after  many  months  invalidism. 

The  other  case  was  that  of  a man  under  middle 
age  who  had  a precisely  similar  condition,  involving 
the  entire  penis,  anterior  portion  of  the  scrotum  and 
the  inguinal  and  femoral  glands.  This  case  was  in 
the  hospital  for  four  years  and  was  treated  in  every 
conceivable  way' without  effect.  He  finally’  drifted 
into  a homeopathic  hospital  and  died,  after  having 
achieved  a tremendous  reputation  as  a patholigical 
curiosity  and  a perpetual  clinic.  This  man  was  a 


41 


robust  person  originally,  who  had  been  syphilized. 
The  local  infection  which  finally  destroyed 
life  was,  in  all  probability,  in  no  wise 
different  in  these  two  cases  from  that  in 
thousands  of  other  cases  of  chancroid,  but 
observe  the  difference  in  results.  Surely  there  must 
be  some  special  condition  behind  such  cases.  This 
I have  already  expatiated  upon. 

The  possibilit}'^  of  these  cases  having  been  tuber- 
culous may  suggest  itself  at  this  point.  Although  I 
saw  these  cases  before  the  question  of  the  tubercle 
bacillus  had  assumed  very  definite  proportions,  and 
consequently  cannot  speak  authoritively,  I do  not 
believe  they  were  tubercular  in  character.  Neither 
case  developed  tubercle  elsewhere  and  both  cases 
were  of  long  duration.  It  is  probable  that  some  few 
cases  of  so-called  esthiomene  have  been  of  a tuber- 
culous nature.  There  is  a form  of  local  ulcer  occa- 
sionally seen  which  begins  as  rounded,  dark-red  or 
purplish  tubercles,  finally  forming  ulcers  with  a fun- 
gous, granulating  surface,  free  purulent  secretion, 
and  hard  everted  borders.  Taylor  has  seen  three 
cases  of  this  kind,  and  following  Hardy  and  Bazin, 
classifies  them  as  “ scrqfiilide  tuberculeusc  ulcer eitseP 
These  cases,  however,  he  observed  before  the  ad- 
vent of  the  bacillus  tuberculosis.  In  one  case  pul- 
monary phthisis  existed.  Taylor  concludes  from  his 
observations,  “ That  vulvar  ulcers,  not  hyperplasite 
or  hypertrophies,  may  be  very  rarely  caused  by 
tuberculous  infection  and  that  they  should  be  in- 
cluded in  our  classification.  If  it  is  hereafter  estab- 
lished beyond  all  question  that  lupus  and  tuberculo- 
sis are  wholly  identical  in  their  nature  and  clinical 
history,  we  shall  then  have  to  admit  that  there  is  a 
lupus  of  the  external  female  genitals.  In  the  mean- 
time we  can  content  ourselves  with  the  thought  that 


42 


what  has  heretofore  been  considered  as  lupus  on 
these  parts  is  not  lupus  at  all.”  There  is  a peculiar 
form  of  chronic  vulvar  lesion  described  in  former 
times  as  oozing  tumor,  and  cases  of  which  were  re- 
ported hy  Duncan,  as  lupus  and  hemorrhagic  lupus, 
which  are  of  interest.  Taylor  attributes  the  so- 
called  hemorrhagic  condition  to  the  excoriation  of 
coapted  hypertrophic  surfaces,  and  the  consequent 
exudation  of  serum  or  sero-sauguinolent  fluid.  I 
observed  one  case  in  the  New  York  Charity  Hos- 
pital which  was  quite  typically  hemorrhagic.  The 
woman  had  been  syphilized,  and  contracted  achan- 
croid  which  became  chronic.  Pregnacy  occurred 
and  soon  afterward  the  labia  became  enormously- 
swollen  and  painful.  Hemorrhage  from  the  affected 
part  soon  began  and  the  pain  was  relieved,  but  the 
parts  settled  down  in  a state  of  obstinate  chronicity-. 
The  hemorrhage  persisted  constantly^  Notwith- 
standing the  fact  that  confinement  occurred  in  the 
venereal  ward,  which  was  filled  with  the  worst  class 
of  cases,  and  despite  the  local  condition  which  so 
favored  septiccemia,  the  woman  not  only  convalesced 
satisfactorily,  but  her  local  lesion  entirely  healed  in 
a few  weeks.  The  relation  of  the  pregnacy  to  the 
hemorrhagic  condition  of  the  lesion  is  obvious.  The 
child  of  this  woman,  by  the  way,  subsequently-  died 
of  meningeal  hemorrhage  of  distinctively  sy^philitic 
origin. 


ABERRANT  SEXDAL  DIFFERENTIATION, 


The  subjects  of  imperfect  or  aberrant  sexual  differ- 
entiation are  much  more  numerous  than  is  generally 
supposed,  but  fortunately  the  majority  of  cases  are 
either  slightly  marked  or  of  little  practical  importance 
as  regards  their  physiological  and  social  relations. 

Time  was  when  certain  marked  cases  of  physical 
deformit}^  were  of  vital  importance  to  medical  jurists, 
and  hermaphroditism,  so-called,  received  considerable 
attention  on  the  part  of  authorities  upon  jurisprudence. 
Thus  in  England, where  the  law  of  primogeniture  exists 
and  the  male  is  therefore  relatively  so  important  a 
factor  in  the  body  social,  the  traditions  of  law  upon 
hermaphroditism  still  prevail  to  a certain  extent. 

As  our  knowledge  of  physiology  and  morphology  has 
advanced,  however,  the  so-called  hermaphrodite  has 
not  only  decreased  in  numbers,  but  is  no  longer  of 
such  vital  importance.  The  principal  feature  of  such 
cases  no\v-a-days  is  the  question  of  impotence  on  the 
one  hand,  and  sterility  on  the  other. 

Hermaphroditism  in  its  literal  sense  implies  a ming- 
ling of  the  physical  and  functional  characters  of  both 
sexes,  the  crucial  test  being  at  the  present  day  the 
existence  of  a more  or  less  perfectly  formed  testicle 
and  ovar}7  in  the  same  individual.  In  this  sense  there 
is,  as  far  as  I am  aware,  not  a single  case  of  hermaph- 
roditism on  record.  I am  aware  that  such  are  described. 


44 

but  I do  not  admit  their  authenticity.  It  is  admitted, 
however,  that  cases  are  occasionally  seen  which 
require  great  diagnostic  acumen  for  their  differentia- 
tion. An  illustration  of  this  occurred  in  Paris  several 
years  ago.  A case  coming  under  the  observation  suc- 
cessively of  Guyon  and  Fournier,  was  in  a lengthy 
opinion  positively  asserted  to  be  male  by  one,  and 
quite  as  positively  pronounced  a female  by  the  other 
of  these  eminent  gentlemen. 

Many  cases  occur  in  v/hich  a diagnosis  is  impossi- 
ble until  the  age  of  pr.terty,  when  certain  sexual  pro- 
clivities— menstruation,  the  development  of  beard, 
changing  voice,  etc.,  as  the  case  may  be — decide  the 
question  of  sex.  It  is  a fact  that  in  marked  cases  of 
so-called  hermaphroditism,  the  afflicted  person  not 
only  has  not  a mixture  of  male  and  female  organs,  but 
is  practically  a neuter,  being  incapable  of  exercising 
the  functions  of  either  sex.  When,  howmver,  the  sub- 
ject of  general  malformation  is  also  a sexual  pervert, 
appearances  ma}'^  indicate  an  apparent  commingling 
of  the  functional  capacity  of  both  sexes.  A case 
which  came  under  my  own  observation  aptly  illustrates 
this  : A “hermaphrodite”  mulatto  cook  in  my  neigh- 

borhood not  only  had  intercourse  wnth  women,  but 
was  in  the  habit  of  enticing  young  lads  into  attempting 
connection.  An  endemic  of  gonorrhoea  among  the 
lads  of  the  locality  led  me  to  investigate  the  source  of 
the  disease  and  I readily  traced  it  to  the  negro  h}'pos- 
padiac. 

Aberrant  sexual  differentiation  is  not  always  ph}’- 
sical  but  may  be  functional,  i.  e.,  dependent  upon  im- 
perfect differentiation  of  sexual  affinit)'.  As  sexual 
affinity  is  but  a form  of  “hunger”  (Clevenger,  op.  cit.')* 
or  chemical  affinit}',  sexual  perversion  might  naturally 
be  expected  to  result.  It  may  be  seen  therefore  that 
paederasts,  urnings  (Caspar,  op.  «'/.')  and  other  sexual 
perverts  are  really  akin  to.  epispadiacs  and  hypospa- 
diacs. 

The  subjects  of  imperfect  sexual  differentiation  may 
be  classified  as  follows  : 


* I 


‘Physiology  and  Pathology,”  S.  V.  Clevenger. 


45 


1.  Imperfect  differentia- 
tion of  sexual  affinity  with- 
out defective  structure. 


i Paederasts,  timings, 

I Subjects  of  bestiality, 
r Affinity  of  the  female  for 
J her  own  sex. 


im- 


2.  Defective  (/.  e., 
perfect  differentiation  of) 
structure.  ' 


a.  Simple  e. , with 
normal  sexual  appetite). 

b.  Complex  {i.e.,  with 
J perverted  sexual  appetite) 

Under  this  head  comes  some  cases  of  hypospadias 
and  epispadias,  and  certain  cases  of  rudimentary  con- 
dition or  absence  of  uterus,  ovary,  testicle  and  penis. 

In  an  old  work  upon  jurisprudence  (Guy,  op.  cit.) 
cases  of  sexual  peculiarity  (/.  e.,  physical  malforma- 
tion) are  classified  as  follows  : 


1.  Male  individuals  with  such  unusual  formations 
of  the  generative  organs  as  in  many  respects  to  resem- 
ble the  female. 

2.  Female  individuals  with  such  unusual  formation 
of  the  same  organs  as  to  resemble  the  male. 

3.  Where  a mixture  of  the  sexual  organs  of  both 
sexes  is  exhibited  without  either  being  entire. 

It  is  obvious  that  there  are  certain  acquired  condi- 
tions which  would  fall  under  the  above  classification 
which  would  not  be  true  cases  of  aberrant  sexual  dif- 
ferentiation ; e.  g.,  a prolapsed  and  hypertrophied 
uterus  has  been  mistaken  for  a rudimentary  penis,  and 
females  thus  afflicted  have  been  known  to  copulate 
with  other  females.  An  hypertrophied  clitoris  may 
be  mistaken  for  a rudimentary  penis. 

The  importance  of  caution  in  deciding  the  sex  in 
cases  of  genital  malformation  is  aptly  illustrated  by  a 
comparatively  recent  case  occurring  in  this  city.  In 
this  case  society  was  electrified  by  the  discovery  that 
a supposed  young  lady  who  had  been  visiting  about 
and  sleeping  with  bona  fide  young  lady  friends,  was  a 
boy.  The  first  intimation  of  the  truth  was  the  devel- 
opment of  a pronounced  beard  with  a bass  vocal  ac- 
companiment. 

There  was  considerable  anxiety  for  a time  lest  the 
supposed  girl  had  discovered  his  meritorious  qualities 
prior  to  their  detection  by  others.  He  naively  con- 


46 

fessed  that  “it  always  did  make  him  feel  funnj’’ to 
sleep  with  the  girls.” 

The  assertion  that  certain  cases  of  sexual  perversion 
are  akin  to  epispadias  and  hypospadias  and  the  result 
of  imperfect  differentiation,  may  seem  a trifle  far 
fetched,  but  I hold  to  the  opinion  that,  even  when  the 
differentiation  of  sex  is  complete  from  a gross  physi- 
cal standpoint,  it  is  still  possible  that  the  receptive 
and  generative  centers  of  sexual  sensibility  may  fail 
to  become  perfectly  differentiated.  The  result  under 
such  circumstances  might  be,  on  the  one  hand,  sexual 
apathy,  and  upon  the  other,  an  approximation  to  the 
male  or  female  type  as  the  case  may  be.  Such  a fail- 
ure of  development  and  imperfect  differentiation  of 
structure  would  necessarily  be  too  occult  for  detection 
from  a physical  standpoint  by  any  means  of  investi- 
gation at  our  command.  It  is,  however,  only  too  well 
recognized  by  its  results  and  is  often  responsible  for 
disgusting  cases  of  sexual  perversion  which  we  are 
prone  to  attribute  to  moral  depravit3^  I have  else- 
where elaborated  this  point,  and  upon  the  relation  of 
reversion  of  type  to  sexual  perversion.  (^Philadelphia 
Medical  and  Surgical  Reporter,  September  7th,  1889.) 
Thus  a failure  of  development  is  equallj'  responsible 
for  certain  cases  of  sexual  perversion  and  instances  of 
hypospadias  and  epispadias. 

Cases  of  gross  physical  aberration  of  genital  struc- 
ture are  not  difficult  to  account  for,  as  far  as  the  mo- 
dus operand!  of  their  formation  is  concerned,  but 
their  cause  is  not  so  readil}?  explicable.  How  far  ma- 
ternal impressions  enter  into  the  causation  of  genital 
deformity  is  a question  upon  which  it  is  to  be  hoped 
much  light  maj^  some  day  be  shed.  There  is  evidentl}' 
an  exhaustion  of  formative  energv'’  before  complete 
fusion  of  the  two  lateral  segments,  of  which  the  em- 
bryo is  practically  composed. 

Defective  genital  formation  bears  the  same  relation 
to  this  exhaustion  of  formativm  energjq  as  do  crania 
bifida,  spina  bifida,  etc.  It  is  obvious  that  the  degree 
of  deformity  depends  entirel}^  upon  the  period  at 
which  developmental  progression  ceases.  As  far  as 
appearances  go,  we  would  naturally  conclude  that  dif- 


47 

ferentiation  does  not  cease  at  a very  early  period  in 
the  life  history  of  the  foetus,  else  true  hermaphrodit- 
ism would  not  only  occur  in  reality,  but  would  be  fre- 
quent. 

Geoffroy  St.  Hiliare,  one  of  the  older  writers,  mapped 
out  a very  elaborate  plan  in  explanation  of  hermaphro- 
ditism in  a work  especially  devoted  to  that  subject. 
He  divided  the  generative  apparatus  into  a series  of 
portions  or  segments,  three  in  each  lateral  division. 
The  upper  set  comprised  the  testes  and  ovaries,  the 
middle  the  womb,  prostate  and  vesiculae  seminalis, 
the  lower  the  penis  and  scrotum,  clitoris  and  vulva. 
According  to  him,  therefore,  there  might  occur  any 
number  of  varieties  of  hermaphroditism,  according 
to  the  combination  of  defective  structures.  This 
scheme  was  defective  because  of  the  fact  that,  in 
spite  of  all  appearances  to  the  contrary,  differentiation 
never  falls  short  of  determining  one  or  the  other  sex. 

The  simplest  plan  for  the  explanation  of  genital  de- 
formities and  anomalies  is  to  remember  that  the  foetus 
practically  develops  in  two  halves,  and  that  any  fail- 
ure of  union  at  the  genital  furrow  will  result  in  a 
greater  or  less  degree  of  aberration  of  genital  forma- 
tion. 

The  relation  of  aberrations  of  genital  formation  to 
sterility  and  impotence  is  very  important.  Impotence 
does  not  exist  in  the  female  unless  there  be  atresia  or 
complete  absence  of  the  vagina.  Almost  any  aberra- 
tion of  the  structure  of  the  ovary  or  uterus  will,  how- 
ever, produce  sterility.  In  the  male  impotency  is  more 
apt  to  result  than  sterility,  as  serious  deformity  may 
prevent  erection,  or  sufficient  development  of  the 
organ  to  prevent  intromission.  No  matter  how  great 
the  deformity,  however,  the  individual  maybe  fruitful 
if  circumstances  be  favorable,  as  long  as  the  testicles 
are  functionally  perfect. 

In  determining  the  sex  of  alleged  hermaphrodites, 
the  following  points  require  consideration  ; 

1.  The  character  of  the  voice. 

2.  The  development  of  the  mammae. 

3.  The  growth  or  absence  of  beard. 

4.  The  form  of  the  shoulders,  hips  and  waist. 


48 

5-  The  presence  or  otherwise  of  the  menses  or 
vicarious  discharges. 

6.  The  character  of  sexual  desire.  (In  respect  to 
this  point,  the  occasional  coexistence  of  sexual  per- 
version with  genital  deformity  should  be  given  its  due 
meed  of  consideration.  Thus  in  a case  in  which  diffi- 
culty of  diagnosis  existed  a perverted  sexual  affinity 
for  the  same  sex  might  mislead  the  physician.) 

7.  The  presence  or  absence  of  rudimentary  (or 
perfect?)  testes  and  ovaries. 

8.  The  form  of  the  supposed  clitoris  or  penis,  the 
method  of  attachment  of  its  prepuce  and  the  absence 
or  presence  of  perforation. 

9.  The  presence  or  absence  of  the  hymen  (rudi- 
mentary), nymphae,  labia  majora  or  bifid  scrotum,  as 
the  case  may  be. 

In  cases  of  doubt  it  is  safest  to  regard  the  individ- 
ual as  a female  until  time  and  pubescence  have  settled 
the  question. 

The  cases  of  imperfect  or  aberrant  sexual  differ- 
entation  included  under  the  head  of  sexual  perversion, 
are  obviously  more  difficult  to  study  than  those  in 
which  the  aberration  is  of  a purely  pli5^sical  character. 
This  is  especially  true  regarding  the  sapphic  love,  or 
sexual  affinity  of  female  for  female.  That  such  cases 
are  frequent  I am  convinced,  but  they  are  extreme!}’ 
difficult  to  trace  ; the  confessional  of  the  family  phy- 
sician doubtless  might  offer  evidence  of  a clinical 
character,  but  the  ph5'sician  is  very  chary  of  airing  the 
short-comings  of  his  patients  in  this  particular  direc- 
tion. The  existence  of  this  aberrant  sexuality  can 
only  be  explained  by  the  theor}'-  of  reversal  of  type. 

In  the  case  of  the  male,  instances  are  so  common 
that  the  subject  is  decidedl}^  trite.  It  is  not  onl}' 
charity,  but  a sense  of  justice  and  a desire  to  lessen 
the  stigma  upon  human  nature,  that  impels  me  to 
include  cases  of  sexual  perversion  under  the  head  of 
aberrant  sexual  differentiation,  and  to  attribute  the 
condition  to  perverted  or  imperfect  evolutionar}' 
development  on  the  one  hand,  and  a reversal  of  type 
on  the  other. 


A PLEA  FOR  EARLY  OPERATIVE 
INTERFERENCE  IN  ACUTE 
PERITONITIS,  WITH  ES- 
PECIAL REFERENCE 
TO  THE  SO-CALLED  IDIOPATHIC 
PERITONITIS  IN  CHILDREN. 


A perusal  of  the  record  of  results  of  strictly 
medical  treatment  in  acute  peritonitis,  since  that 
disease  was  established  as  an  entity  by  Bichat,  in 
1802,  is  not  conducive  to  professional  conceit. 
Before  the  introduction  of  the  opium  treatment 
by  the  late  Dr.  Alonzo  Clark,  in  1850,  the  dis- 
ease was  almost  invariably  fatal.  Prior  to  Clark’s 
innovation  opium  had  been  given  in  moderate 
doses  by  Stokes,  Graves  and  others,  for  its  ano- 
dyne effect.  Clark,  however,  advocated  putting 
the  bowels,  as  he  expressed  it,  in  “opium 
splints  ’ ’ through  the  medium  of  full  narcotic 
doses  of  the  drug.  According  to  this  eminent 
authority  the  criterion  for  the  administration  of 
the  drug  is  the  production  of  the  following  symp- 
toms : “Subsidence  or  marked  diminution  of 

the  pain  ; some  or  considerable  tendency  to  sleep; 
contraction  of  the  pupils  ; reduction  of  the  breath- 
ing to  twelve  respirations  per  minute.  In  the 


50 


favorable  cases  a considerable  reduction  in  the 
frequency  of  the  pulse  ; a gentle  perspiration  and 
itchy  state  of  the  skin,  or  oftener  the  nose.  Ab- 
solute inactivity  of  the  bowels,  and  after  a time 
subsidence  of  tumescence  and  tenderness  and 
some  suffusion  of  the  eyes.” 

This  treatment  was  immediately  adopted  by 
the  majority  of  progressive  physicians  as  a rou- 
tine measure,  and  has,  strange  to  say,  for  forty 
years  been  the  main  reliance.  Reaction  against 
this  routinism  is  but  just  now  attaining  prom- 
inence In  no  other  field  of  medicine  has  there 
been  a less  pronounced  spirit  of  progressiveness 
during  all  these  years  than  in  the  treatment  of 
peritonitis.  The  ready  adoption  of  the  opium 
method  and  the  implicit  reliance  w^hich  was  placed 
upon  it,  was  probably  due  to  the  fact  that  previous 
methods  of  treatment  had  signally  failed,  and  the 
new  method  had  at  least  the  merit  of  saving  a 
certain  proportion  of  cases,  and  under  its  use  the 
sufferer  from  the  disease  was  certainly  comforta- 
ble. As  compared  with  the  success  attainable  in 
other  acute  inflammatory  affections,  the  opium 
treatment  of  peritonitis  has  not  proved  a brilliant 
success. 

In  an  excellent  article  upon  peritonitis.  Dr. 
Stiles  Kennedy,'  of  St.  Louis,  Mich.,  concisely 
presents  the  true  status  of  the  opium  treatment 
when  he  sa5"S  : ‘ ‘ Speaking  for  m3^self,  wuth 

thirty  years’  active  practice,  I pronounce  the 
treatment  a miserable  failure.  All  patients  do 
not  die  under  the  opium  treatment,  but  75  per 
cent,  of  them  do.”  With  a much  shorter  period 
of  observation,  the  brevity  of  w'hich,  however, 
has  perhaps  been  compensated  for  iu  a measure 
by  several  years  hospital  experience,  I can 
heartily  endorse  Dr.  Kenned3^’s  position.  Great 
as  was  the  advance  in  therapeutics  instituted  b3' 
Dr.  Clark,  it  unfortunately  came  to  be  regarded 
as  the  ultima  thule  of  therapeutics  of  abdominal 
inflammations.  Who  is  there  here  but  will 
bear  me  out  in  the  assertion  that  an3^  attempt  to 


I American  Lancet,  December,  1SS9. 


51 


classify  and  differentiate  abdominal  inflamma- 
tions with  regard  to  a discriminating  selection  of 
therapeutical  methods,  has  usually  been  regarded 
as  rank  heresy, — I was  going  to  say  malpractice, — 
ever  since  the  opium  treatment  came  in  vogue  ? 
Even  those  who  have  discriminated  between  trau- 
matic and  so-called  idiopathic  cases  of  peritonitis 
have  failed  until  quite  recently  to  discriminate  in 
the  matter  of  treatment.  Septic  cases,  in  which 
apparently  the  principal  object  to  be  attained  is 
the  draining  away  of  putrid  materials  both  from 
the  abdominal  cavity  direct  and  via  the  intestinal 
canal,  have  been  treated  upon  the  same  principles 
as  cases  which  were  apparently  of  non-septic 
origin. 

There  is  a feeling  at  present  among  progressive 
physicians, — and  to  strengthen  this  is  the  princi- 
ple object  of  this  paper, — that  peritonitis  is,  so  to 
speak,  more  of  a surgical  disease  in  general  than 
it  has  been  regarded  heretofore.  Speaking  for 
myself,  with  a keen  realization  of  the  hopeless- 
ness of  the  majority  of  cases  when  medically 
treated,  and  I believe,  with  a proper  appreciation 
of  the  origin  of  the  disease  in  the  majority  of 
cases,  I feel  warranted  in  the  assertion  that  peri- 
tonitis should  nearly  always — I was  going  to  say 
invariably — be  relegated  to  the  domain  of  surgery. 
To  put  it  vulgarly,  I might  support  this  position 
by  the  assertion  that  the  physician  has  had  an 
inning  of  forty  years’  duration,  which,  to  carry 
the  base-ball  phraseology  a little  further,  has  re- 
sulted in  a “goose  egg.’’  It  is  but  fair  that  the 
surgeon  now  be  given  a chance  to  compare 
methods  at  least  ; as  far  as  experience  has  gone 
the  results  of  surgery  are  certainly  more  encourag- 
ing than  those  attained  by  medical  treatment. 
The  more  thoroughly  the  pathology  of  peritoni- 
tis is  studied  the  more  obvious  the  truth  of  this 
assertion  becomes.  Like  most  surgeons,  I now 
see  few  cases  of  peritonitis  which  are  not  dis- 
tinctly recognized  as  traumatic.  As  most  cases 
are  supposed  to  be  idiopathic,  the  surgeon  sees 
comparatively  few  such.  I believe,  however,  that 


52 


a proper  appreciation  of  the  true  pathological  and 
etiological  status  of  the  disease  on  the  part  of  the 
general  practitioner  will  enable  the  surgeon  to 
observe  and  treat  such  cases  more  frequently. 

The  etiology  of  peritonitis  has  attracted  con- 
siderable attention.  It  has  usually  been  divided 
into  idiopathic  (primary  and  secondary),  and 
traumatic. 

I have  no  hesitation  in  putting  m5"self  upon 
record  as  believing  that  there  is  no  such  thing 
as  primary  idiopathic  peritonitis.  The  more 
carefully  we  inquire  into  the  history  of  the 
disease,  the  narrower  the  range  of  the  .so-called 
idiopathic  cases  becomes.  To  attribute  the  dis- 
ease in  the  absence  of  any  known  organic  cause, 
to  exposure  to  cold,  dietary  indiscretions,  etc. , is, 
it  seems  to  me,  simply  a substitute  for  an  honest 
expression  of  ignorance.  That  the  disease  may 
be  secondary  to  certain  constitutional  affections 
is  probably  correct.  It  has  been  attributed  to 
rheumatism,^  erysipelas,^  and  the  various  erup- 
tive fevers,  especially  scarlatina,^  equinia  or  glan- 
ders,® septicaemia,  and  purulent  infection.®  Its 
dependence  upon  puerperal  septicaemia,  uterine 
and  pelvic  inflammations  is  well  known.  Anstie 
describes  epidemic  infectious  peritonitis  as  being 
due  to  sewer  gas.  Certain  chronic  constitutional 
diseases,  such  as  gout,  Bright’s  disease,  and 
tuberculosis  are  well  known  causes.  Renal  dis- 
ease, as  a cause  of  abdominal  inflammation,  is 
mentioned  by  several  excellent  authorities.' 

Traumatic  peritonitis  is  not  always  easily 
traced  to  its  cause.  There  are  many  cases  of 
course  which  are  readily  so  traced.  A histor}'  of 
injury  with  palpable  lesion,  either  in  the  form  of 
penetrating  wounds,  or  such  conditions  as  con- 
tusion or  rupture  of  the  liver,  spleen,  stomach, 


zVivaut,  1SS4. 
sCheurlin,  1879. 

4Moor.  Dublin  Journal  Medical  Sciences,  1S76. 

5 Mahomet.  Schmidt’s  Jahrbiicher,  1SS4. 

6 Hilton  Fagge.  1873. 

7Woillez.  Bull,  de  la  Soc.  Med.  des  Hop.,  1885.  Hilton  Fagge. 
Guy’s  Hospital  Reports,  1873-1875. 


53 


intestines,  kidneys,  bladder,  or  womb  is  most 
usually  elkited. 

The  relation  of  cause  and  effect  is  sufficiently 
plain  in  the  case  of  operative  interference  with 
the  abdominal  cavity  or  its  contents.  Certain 
rough  manipulations  of  the  abdomen  have  been 
known  to  produce  the  disease.  Compression  of 
the  left  ovary  in  an  hysterical  woman  has  been 
known  to  produce  it.®  I mention  this  especially 
to  show  how  slight  a cause  is  sometimes  sufficient .  *  * 
The  dependence  of  the  disease  upon  minor  gyne- 
cological operations,  intestinal  perforation  from 
various  causes,  such  as  typhoid  fever,  typhlitis, 
perityphlitis,  etc.,  is  well  recognized. 

Although  it  is  supposed  that  idiopathic  perito- 
nitis may  occur  at  any  age  up  to  that  of  55  years, 
it  is  a well  recognized  fact  that  ‘ ‘ idiopathic  cases 
are  relatively  much  more  frequent  in  children,  the 
frequency  being  in  inverse  proportion  to  the  age. 

Children  are  very  often  taken  with  the  disease 
while  apparently  in  a condition  of  perfect  health. 
This,  it  seems  to  me,  is  in  itself  inconsistent  with 
the  idiopathic  theory  ; — a fact  which  is  significant 
is  that  adhesions  and  pus  are  an  almost  invariable 
result  of  idiopathic  peritonitis.  One  of  the  best  ar- 
guments in  favor  of  surgical  interference  that  I have 
seen  is  the  naive  assertion  of  Gauderon  that  recov- 
ery sometimes  follows  the  escape  of  pus  through 
the  umbilicus.  This  mode  of  termination  was 
noticed  by  him  in  eleven  cases  out  of  twenty-five, 
and  of  these  eleven  cases  there  were  eight  recov- 
eries. It  would  be  interesting  to  note  how  many 
of  the  remaining  fourteen  cases  recovered,  as 
showing  in  how  far  the  chances  of  recovery  were 
directly  dependent  upon  the  exit  of  the  pus  ; 
i.  e.,  in  how  far  nature’s  surgery  was  a hint  to  the 
surgeon. 

It  has  occurred  to  me  that  the  reason  for  the 
greater  apparent  frequency  of  idiopathic  peritoni- 


8 Comby.  De  Bull,  de  la  Soc.  Anat.,  1880. 

* There  was  possibly,  in  this  instance,  tubal  disease,  the 
contents  of  the  tube  being  discharged  or  its  walls  ruptured  by  the 
tianipulation. 


54 


tis  in  children  is  due  to  their  inability  to  describe 
the  particular  accident  to  which  the  inflammation 
should  properly  be  attributed.  Children  receive 
so  many  bumps  and  falls  that  even  when  well  ad- 
vanced in  years  they  are  not  likely  to  attribute 
any  special  importance  to  any  particular  accident. 
The  peritoneum  being  more  sensitive  in  children 
their  greater  susceptibility  to  peritonitis  from 
slight  injuries  is  at  once  obvious. 

Leaving  secondary  peritonitis  out  of  the  ques- 
tion, I do  not  believe  in  the  existence  of  the  idi- 
opathic variety  of  the  disease  in  young  children. 
It  is  very  easy  to  injure  the  peritoneum,  especially 
in  young  subjects  in  whom  the  strength  and  thick- 
ness of  the  abdominal  walls  are  by  no  means  pro- 
portionate to  the  responsibility  of  protecting  the 
viscera.  Abdominal  fat  in  young  children,  for  ex- 
ample, is  not  very  abundant.  The  sensitiveness 
ot  the  abdominal  contents  in  children  to  various 
causes  of  irritation  is  a well  recognized  explanation 
of  the  ext:essive  mortality  rate  of  childhood.  Not 
only  are  the  viscera  relatively  more  sensitive  than 
in  the  adult,  but  the  peritoneum  is  also  a loais  mi- 
noris  resistenticB.  Injuries  which  are  so  slight  as 
to  be  innocuous  to  the  adult  may  produce  perito- 
nitis in  young  children.  I believe  that  peritonitis 
in  young  children  follows  very  often  injuries  so 
slight  that  the  child  never  complains  of  them.  I 
am  firmly  convinced  that  the  so-called  idiopathic 
peritonitis  always  follows  a lesion  of  greater  or 
less  severity.  Severe  strainings  at  stool,  blows 
upon  the  abdomen  producing  bruising  of  the  in- 
testines, parietal  or  visceral  peritoneum  or  mesen- 
tery may  produce  it.  Comparatively  slight 
violence  exerted  upon  the  stomach  when  full, — 
and  we  all  know  how  disproportionately  promi- 
nent the  distended  stomach  in  young  children  is, 
— may  give  rise  to  peritonitis.  Verj^  slight  in- 
juries to  other  viscera  and  especiall}’-  the  liver, 
may  give  rise  to  the  disease.  The  bruising  ma}' 
be  so  slight  as  to  leave  no  trace  which  is  visible 
post-mortem,  and  j^et  be  sufficient  to  light  up 
general  peritonitis.  A bruise  over  the  distended 


55 


bladder,  or  if  the  bladder  be  not  bruised,  a wrench 
of  its  peritoneal  attachments  incidental  to  a fall, 
may  give  rise  to  the  disease. 

A point  which  I desire  to  again  emphasize  is 
the  disproportionate  size  and  weight  of  the  ab- 
dominal contents  in  young  children,  as  contrasted 
with  the  natural  provisions  for  their  protection. 
As  a corollary  of  this  point,  I venture  the  asser- 
tion that  falls  and  jars  may  in  children  produce 
concussion  of  the  abdominal  contents  with  re- 
sultant strain  (with  or  without  slight  rupture), 
of  those  retentive  ligaments  which  are  either  de- 
rived from  or  invested  by  the  peritoneum.  There 
is  certainly  in  young  children  considerable  dispro- 
portion between  the  strength  of  these  retentive 
ligaments  and  the  weight  and  dimensions  of  the 
organs  w'^hich  they  are  intended  to  support. 

A cause  of  peritonitis  in  children,  which  I be- 
lieve will  in  the  years  to  come  be  more  frequently 
recognized,  is  inflammatory  affections  in  the  region 
of  the  caecum.  I believe  that  typhlitis  and  peri- 
typhlitis, due  to  enteroliths  or  other  foreign  bodies 
in  the  vermiform  appendix,  constitute  one  of  the 
most  frequent  causes  of  so-called  idiopathic  peri- 
tonitis in  young  children.  The  reason,  it  seems 
to  me,  that  this  is  not  more  frequently  recognized 
is  the  fact  that  in  children  the  disease  runs  a very 
rapid  course,  has  a more  pronounced  tendency  to 
general  extension,  and  kills  the  little  patient  before 
those  tardy  evidences  of  localized  inflammation 
and  suppuration  are  recognized  by  the  physician. 
How  frequently  we  overlook  cases  of  perityphlitis 
in  the  adult,  treating  them  perhaps  for  typhoid 
fever  or  some  other  disease  for  days  or  perhaps 
weeks  before  we  are  enabled  to  make  a positive 
diagnosis.  It  is  all  very  well  for  the  surgeon 
who  is  called  in  at  the  eleventh  hour,  to  criticise 
the  physician  for  failing  to  discover  the  pathogno- 
monic induration  in  the  ileo-caecal  region  at  an 
earlier  day,  but  there  is  a question  in  my  mind 
whether  the  surgeon  himself  in  many  instances 
could  have  done  any  better.  With  a full  realiza- 
tion of  the  possibilities  of  error  in  the  differenti- 


55 


ation  of  typhoid  and  perityphlitis,  I will  confess 
that  I have  myself  remained  in  doubt  for  da5^s  at 
a time,  in  cases  in  which  I afterwards  operated. 
If,  then,  we  make  such  mistakes  in  the  case  of  the 
adult,  how  much  more  likely  are  we  to  overlook 
until  too  late,  localized  inflammation  in  the  child. 

The  disease  begins  abruptly,  extends  quickly, 
and  within  a very  few  hours  perhaps  we  may  have 
an  enormously  distended  abdomen  and  all  of 
those  physical  conditions  which  absolutely  pre- 
clude that  careful  and  thorough  examination  which 
might  insure  an  accurate  diagnosis.  Often,  in  my 
opinion,  the  little  patient  will  die  of  acute  general 
peritonitis  which  has  originated  in  perityphlitic 
inflammation  long  before  an  adult  would  perish 
under  the  same  conditions.  The  formation  of 
lymph,  plastic  material,  and  protective  adhesions 
does  not  occur  in  the  child  because  of  the  rapid 
extension  of  the  inflammation.  The  child  dies  un- 
operated on,  and  the  case  is  recorded  as  another 
sad  illustration  of  the  fatality  of  idiopathic  peri- 
tonitis in  children.  Authorities  are  united  in  the 
opinion  that  pus  is  rapidly  and  almost  invariably 
formed  in  the  peritoneal  cavity  in  children.  As 
already  stated,  a number  of  cases  of  recovery  have 
occurred  in  which  the  pus  escaped  spontaneous!}". 
Under  such  circumstances  the  chances  of  life  of 
the  patient  are  entirely  dependent  upon  the  caprice 
of  nature.  If  the  pus  escapes  early  enough  or 
burrows  in  a favorable  direction  the  patient  may 
recover.  If  nature  is  unkind,  death  results. 

In  a general  description  of  perityphlitis,  Drs. 
E.  W.  Lee  and  J.  B.  Murphy,  well  known  and 
competent  surgeons  of  Chicago,  concisely  state 
the  situation  as  follows;  ‘ ‘ Are  we  doing  our  duty 
to  our  patients  by  allowing  them  to  take  such 
chances?  Why  should  pus  in  this  locality  be  al- 
lowed unaided  to  find  its  favorable  or  unfavorable 
exit,  in  contradistinction  to  the  well  established 
rule  to  properly  aid  its  escape  in  all  other  parts  ot 
the  body  where  accessible  ? Who  has  not  seen  a 
similar  case  to  this?  The  patient  is  taken  sud- 
denly ill,  complains  of  pain  in  the  abdomen  ; has 


57 


vomiting,  a rapid,  feeble  pulse,  and  a pinched, 
anxious  expression  of  countenance.  Examina- 
tion reveals  the  abdomen  to  be  uniformly  distend- 
ed and  sensitive — in  short,  with  all  the  symptoms 
of  acute  peritonitis,  usually  terminating  fatally 
on  the  third  or  fourth  day.  Were  we  permitted  to 
make  autopsies  on  all  of  the  cases  presenting  the 
above  history  we  would  find  that  a large  percentage 
of  them  were  produced  by  the  rupture  of  a perityph- 
litic  abscess  into  the  peritoneal  cavity." 

I will  apply  these  remarks  especially  to  cases 
of  peritonitis  in  children,  and  I believe  that  I am 
warranted  in  asserting  that  in  a large  proportion 
of  cases  of  fatal  so-called  idiopathic  peritonitis  in 
children,  we  would  find,  were  we  permitted  to 
make  an  autopsy,  that  the  disease  had  originated 
in  perityphlitic  inflammation.  Rarely  perhaps 
would  we  find  the  inflammation  to  be  secondary 
to  an  abscess  which  had  ruptured.  To  present 
my  ideas  more  concisely,  I believe  that  many 
cases  of  peritonitis  in  children  are  due  to  peri- 
typhlitic inflammations  which  are  similar  to  those 
occurring  in  the  adult,  with  the  exception  that  in 
the  child  they  are  followed  immediately  by  acute 
general  peritonitis,  while  in  the  adult  intermedi- 
ary changes  about  the  caecum  occur.  In  cases  of 
traumatic  origin,  the  site  of  the  injury  might  es- 
cape observation  because  of  the  rapidity  with 
which  ecchymosis  had  disappeared. 

Regarding  the  dependence  of  peritonitis  in  chil- 
dren upon  slight  traumatism,  I have  in  my  own 
limited  experience  met  with  a number  of  cases 
which  were  supposed  to  be  idiopathic,  but  in 
which  careful  inquiry  elicited  a history  of  slight 
traumatism.  I recall  a case  at  the  present 
moment  of  a child  in  the  neighborhood,  who 
was  not  under  my  care,  who  died  of  what  a 
number  of  competent  physicians  termed  idio- 
pathic peritonitis.  My  wife,  who  was  interested 
in  the  little  one,  was  discussing  the  case  with  me 
one  evening,  and  upon  my  expressing  my  belief 
that  the  child  must  have  been  injured  in  some 
way,  exclaimed : “ Now  I remember,  the  little 


58 

girl  was  playing  with  some  of  the  other  children 
in  front  of  our  house  a day  or  so  before  she  was 
taken  sick,  and  I saw  one  of  the  other  children 
push  her  down.  She  fell  with  her  stomach  across 
a curb-stone.  She  got  up,  cried  for  a few  mo- 
ments, and  then  went  about  her  play  as  if  nothing 
had  happened.” 

The  second  case,  which  came  under  my  obser- 
vation in  consultation,  was  pronounced  idiopathic 
by  two  competent  physicians;  but  careful  inquiry 
among  the  playmates  of  the  boy  revealed  the  fact 
that  he  had  injured  himself  by  jumping  from  the 
roof  of  a shed  two  days  before  he  came  ill.  As 
his  mother  had  forbidden  his  climbing  upon  the 
shed,  he  had  concealed  the  fact  of  the  injury. 
This  concealment  on  the  part  of  young  children 
through  dread  of  parental  sternness  is  in  my  esti- 
mation a frequent  cause  of  obscurity  in  the  etiol- 
ogy of  peritonitis. 

Still  a third  case.  I was  called  by  Dr.  G.  W. 
Reynolds,  of  Chicago,  to  see  a case  of  peritonitis 
from  some  unknown  cause,  and  found  a child  of 
5 years  of  age  already  in  extremis.  On  inquiry"  I 
found  that  the  child  had  recently  been  presented 
with  a velocipede  from  which  he  had  fallen  sev- 
eral times.  He  had  hurt  himself  slightly,  but  not 
.severely  enough  to  attract  attention  on  the  part 
of  his  parents. 

In  this  case,  as  in  the  preceding,  I attributed 
the  peritonitis  to  concussion  of  the  abdominal 
contents.  I have  notes  of  several  other  cases  of 
a like  character,  but  will  not  burden  the  Section 
with  their  recital. 

The  treatment  of  acute  peritonitis  is  undergoing 
a pronounced  change.  Indeed,  the  transition  from 
narcotic  routinism  bids  fair  to  bring  the  profession 
to  the  opposite  extreme.  The  free  administration 
of  laxatives,  especially  those  of  a saline  character, 
is  now  being  advocated  in  some  quarters  quite 
strenuously.  This  is  going  to  the  opposite  extreme 
with  a vengeance.  Once  again,  there  seems  to 
be  a tendency  on  the  part  of  the  profession  toward 
indiscrimination  in  the  proper  selection  of  cases. 


59 


Lawson  Tait  and  Greig  Smith  openly  advocate 
saline  cathartics  in  the  treatment  of  peritonitis  of 
a surgical  character.  Bantock,  however,  opposes 
this.  It  is  not  my  intention  however  to  discuss 
the  merits  and  demerits  of  medical  treatment,  as 
my  paper  is  already  spinning  out  to  an  unwar- 
rantable length. 

The  surgical  treatment  of  peritonitis  is  to  my 
mind  the  most  important  consideration  in  connec- 
tion with  this  disease.  The  trite  aphorism  that 
“history  repeats  itself”  is  well  illustrated  in  the 
case  of  peritonitis.  Erasistratus  and  Soranus  ages 
ago  several  times  cut  into  the  peritoneal  cavity  in 
the  inguinal  region  to  evacuate  pus  accumulated 
in  the  abdomen.  From  this  time,  however,  until 
1735  a period  of  surgical  horror  of  the  abdominal 
cavity  existed,  surgeons  being  afraid  to  touch  the 
peritoneum. 

In  1735  Petit  {Jils)  advocated  operation  for 
peritonitis.  In  1737  he  operated  upon  cases  of 
traumatic  peritonitis,  with  favorable  results.  He 
was  followed  in  1748  by  Garengeot.  Chomel  ad- 
vised operation  to  permit  the  escape  of  effusion 
after  the  subsidence  of  acute  symptoms.  In  1846 
Guerin  advised  copious  irrigation  of  the  peri- 
toneal cavity  with  warm  water  in  generalized 
puerperal  peritonitis,  suggesting  the  removal  of 
effused  fluid  by  aspiration  and  the  injection  of 
warm  water  until  the  liquid  returned  clear.  He 
advised  an  operation  at  the  supervention  of  me- 
teorism.  In  1861  Marten®  advised  the  opening 
of  the  abdomen  with  the  knife,  especially  in  peri- 
tonitis due  to  pathological  perforations.  In  1865 
Keith'®  operated  upon  an  ovarian  cyst  in  a patient 
suffering  from  acute  peritonitis;  recovery  followed. 
In  1876  Kaiser”  reported  several  cases  of  simple 
purulent  and  puerperal  peritonitis  in  which  oper- 
ation proved  successful.  Puerperal  peritonitis 
has  several  times  been  surgically  treated  with 
good  results.  Traumatic  pei  ;tonitis  has  frequently 

9 “Surgical  Treatment  of  Peritonitis,”  Virchow’s  Archives,  20. 
P-  530- 

10  Lancet,  1865,  vol.  xi,  p.  36. 

11  Deutsche  Arch.  f.  Klin.  Med.,  1876,  17,  p.  74. 


6o 


been  treated  by  surgical  interference  since  the 
modern  works  of  Vincent  - Bouilly,  1883,  and 
Chavasse,  1885.  Prior  to  1887  Lawson  Tait  had 
already  operated  upon  nearly  fifty  cases  of  peri- 
tonitis of  all  kinds.  Since  that  date  he  has 
operated  upon  many  others.  He  says  distinctly : 
“Whenever  I find  myself  in  the  presence  of  local- 
ized or  generalized  peritonitis,  whatever  may  be 
the  cause,  I open  the  abdomen  and  treat  the  peri- 
toneum according  to  the  indications  furnished  by 
actual  inspection.  Peritonitis  is,  in  abdominal 
affections,  a most  powerful  indication  for  surgical 
interference.” 

It  has  been  shown  that  a comparatively  slight 
exploratory  incision  will  often  suffice  to  bring 
about  a favorable  result. 

In  concluding  the  general  history’-  of  the  sur- 
gical treatment  of  peritonitis,  I feel  safe  in  assert- 
ing that  it  is  a modern  procedure  which  is  rapidly 
gaining  favor  all  over  the  world. 

I will  now  discuss  briefly  what  appear  to  me 
to  be  the  principal  arguments  in  favor  of  early 
operative  interference  in  peritonitis,  especially  in 
the  grave  forms  of  so-called  idiopathic  peritonitis 
in  children  and  in  traumatic  peritonitis  under  all 
circumstances,  but  more  especially  where  the  in- 
flammation is  generalized,  or  has  resulted  in  the 
local  accumulation  of  pus.  An  important  point 
in  considering  the  surgical  treatment  of  peritonitis 
is  the  analogy  of  the  peritoneal  membrane  to  the 
pleura,  and  other  serous  membranes  to  synovial 
structures.  Inflammations  of  these  tissues  are,  as 
is  well  known,  extremely  painful  and  dispropor- 
tionately depressant.  Much  of  the  pain  and  de- 
pression is  incidental  to  distension  of  the  sensitive 
membrane  by  the  accumulated  products  of  inflam- 
mation. How  frequently  a slight  surgical  pro- 
cedure will  secure  relief  from  the  most  intense 
agony  in  such  conditions  ! Puncture  of  the  an- 
terior chamber  of  the  eye  in  serous  iritis  ; punc- 
ture of  the  tunica  vaginalis  in  cases  of  epididj''- 
mitis;  incision  of  the  tunica  albuginea  in  orchitis; 
aspiration  of  the  thoracic  cavity  in  effusive 


6i 


pleurisy,  are  all  familiar  illustrations  of  this  sur- 
gical principle.  Relief  of  tension  is  the  only 
measure  which  in  such  cases  will  produce  rest. 
The  more  intimately  associated  the  affected  mem- 
brane with  the  sympathetic  nervous  system  and 
with  the  organs  of  vegetative  life,  the  more  severe 
the  agony  and  the  more  pronounced  the  resulting 
depression.  Applying  these  principles,  as  we  all 
do,  to  inflammation  of  other  structures,  why 
should  we  not  apply  them  to  peritonitis  ? What 
membrane  of  the  body  is  more  delicate,  more 
sensitive,  more  important  in  its  physiological 
functions,  more  intimately  associated  with  vital 
organs,  more  intimately  associated  with  the 
lymphatic  system,  and,  most  important  of  all,  so 
intimately  associated  with  the  sympathetic  gan- 
glia, than  is  the  peritoneum?  Taking  these 
things  into  consideration,  is  there  any  wonder 
that  inflammation  of  so  fragile  a structure  pro- 
duces such  a disproportionate  degree  of  vital  de- 
pression ? 

Careful  clinical  observation  has  shown  us  that 
pari  passu  with  the  development  of  meteorism 
and  distension  of  the  abdomen  by  fluid  products 
of  inflammation,  we  have  a pronounced  increase 
in  the  depression  of  the  powers  of  life.  Not  only 
does  inflammation  of  the  peritoneum  per  se  pro- 
duce reflex  inhibition  of  the  cardiac  ganglia,  but 
incidentally  to  meteorism  and  effusion  there  oc- 
cnrs  a direct  mechanical  interference  with  the 
action  of  the  heart.  Does  it  not  seem,  gentlemen, 
that  the  first  indication  in  a case  of  peritonitis  is 
the  relief  of  pressure  and  incidentally  the  removal 
of  gas,  fluid  and  foreign  bodies  ? 

So  profound  is  the  influence  of  abdominal  dis- 
tension upon  cardiac  action  that  we  are  apt  to  be 
misled  in  our  judgment  as  to  the  wisdom  of  an 
operation.  Many  cases  that  seem  too  far  gone  to 
warrant  an  operation  may  recover  if  the  depress- 
ing effects  of  tension  upon  the  peritoneum  and 
abdominal  organs  and  the  mechanical  interference 
incidental  of  meteorism  are  removed  by  opera- 
tion. So  simple  an  operation  as  aspiration  of  the 


62 


intestines  will  often  produce  an  almost  immediate 
relief  from  pain  and  a decided  and  unmistakable 
improvement  in  the  character  of  the  pulse. 

I would  like  to  ask  the  members  of  this  Sec- 
tion whether  there  is,  in  their  estimation,  any  pos- 
sible objection  to  operation  in  cases  of  peritonitis. 
The  indications  for  the  operation  are  plain ; con- 
traindications are  nil.  Should  we  hesitate  to  in- 
terfere with  the  peritoneum,  which  can  under  any 
circumstances  be  interfered  with,  providing  we 
can  prevent  inflammation  and  sepsis?  Should  we 
hesitate,  I say,  when  inflammation  is  already 
present  and  the  conditions  for  sepsis  already  ex- 
ist, and  when,  moreover,  the  only  possible  way  to 
avoid  sepsis  is  to  remove  the  products  of  inflam- 
mation, or  such  foreign  materials  as  may  be  re- 
sponsible for  the  condition  present?  I do  not 
believe  that  judicious  operation  will  in  any  case 
lessen  the  prospect  of  recovery.  I believe,  fur- 
ther, that  delay  in  most  cases  impairs  the  chances 
of  the  patient. 

In  operating,  especially  in  children,  it  is  best 
to  be  conservative.  It  is  possible  to  evacuate 
purulent  and  gaseous  matters  wuthout  super- 
adding to  the  shock  of  the  peritonitis  that  of  an 
extensive  operation.  A small  exploratory  in- 
cision, with  a flushing  out  of  the  peritoneal  cavity 
and  a thorough  washing  of  the  matted  coils  of 
intestine  with  warm  water,  either  plain,  slightly 
saline,  or  impregnated  with  boracic  acid,  will,  in 
my  estimation,  relieve  tension,  favor  asepsis,  and 
save  life  in  many  cases.  While  the  operation 
should  be  done  early  where  practicable,  it  is  my 
belief  that  there  are  few  cases  in  which  the  opera- 
tion is  not  indicated,  providing  the  patient  is  not 
already’m  articulo  ?nortis. 

Since  becoming  conv^erted  to  this  view  my  ex- 
perience has  been  limited  to  a single  case,  which 
I will  briefly  recount. 

Case  I. — This  was  the  case  of  a girl,  7 years  of 
age,  who  fell  against  a table,  injuring  the  abdo- 
men slightly.  She  made  verj'  little  complaint, 
and  it  was  not  supposed  that  the  injurj'  was  of 


63 


any  importance.  On  the  fourth  day  peritonitis 
developed  and  ran  a very  rapid  course.  The 
child,  however,  was  strong  and  vigorous,  and 
although  considerably  prostrated  the  case  seemed 
an  exceptionally  favorable  one  for  surgical  inter- 
ference. On  the  third  day  I proposed  operation, 
which  was  consented  to.  I opened  the  abdomen 
in  the  median  line  by  a small  exploratory  incision 
2 inches  in  length,  punctured  the  intestine  with 
an  exploring  needle  at  all  accessible  points,  and 
flushed  out  the  abdominal  cavity  with  warm 
water  containing  a small  amount  of  boracic  acid. 
I inserted  a small  drainage  tube  and  stitched  the 
incision  about  it  and  dressed  the  wound  antisep- 
tically.  The  operation  of  flushing  was  repeated 
on  three  successive  days,  after  which  time  the 
drainage  tube  was  removed  and  the  wound 
allowed  to  heal,  which  it  did . perfectly.  Relief 
from  the  operation  was  immediate,  and  the  suffer- 
ing of  the  patient  was  at  no  time  thereafter  severe. 
After  the  operation  a full  half  ounce  of  Epsom 
salts  was  administered,  which  resulted  in  ver5’- 
profuse  catharsis.  I could  see  no  possible  objec- 
tion to  this  procedure,  and  I think  that  the  recov- 
ery of  the  patient  was  partly  attributable  to 
it.  It  certainly  appears  to  me  logical  to  apply, 
where  possible,  the  principle  of  depletion  to  in- 
flammations of  the  peritoneum.  This  is  best  se- 
cured by  salines.  I do  not  wish  to  be  understood 
however  as  advocating  the  saline  treatment  as  a 
routine  measure. 

In  conclusion  I will  formulate  my  views  of 
acute  peritonitis  as  follows : 

• I.  I do  not  believe  in  the  existence  of  acute 
idiopathic  primary  peritonitis. 

2.  The  majority  of  cases  of  so-called  idiopathic 
peritonitis  in  children  will  be  found,  upon  inquiry, 
to  be  traumatic. 

3.  Slight  injuries  of  the  abdominal  contents  are 
relatively  more  dangerous  in  children  than  in 
adults. 

4.  Acute  peritonitis  in  children,  while  appar- 
ently idiopathic,  is  often  secondary  to  perityph- 


64 


litic  inflammation,  which  runs  a rapid  course  and 
extends  to  the  general  peritoneum  without  the 
intervention  of  appreciable  local  changes. 

5.  The  profound  prostration  and  cardiac  inhi- 
bition characteristic  of  peritonitis  are  in  a great 
measure  incidental  (i)  to  tension  of  the  perito- 
neum produced  by  inflammatory  products,  with 
a consequent  reflex  inhibition  of  the  heart,  and 
(2)  mechanical  interference  with  the  heart’s  ac- 
tion, 

6.  Surgical  interference  is  indicated  in  all  se- 
vere cases  of  general  peritonitis  and  in  cases  of 
localized  suppurative  inflammation,  or  in  cases  of 
perityphlitic  origin,  whether  due  to  foreign  bodies 
or  not. 

7.  There  is  every  indication  present  for  opera- 
tion, and  no  logical  objection  to  it.  The  opera- 
tion is  almost  invariably  palliative,  if  not  cura- 
tive. 

8.  Operation  in  no  sense  impairs  the  chances 
of  recovery.  Per  contra^  it  enhances  them  to  a 
great  degree. 

9.  No  case  should  be  allowed  to  die  without 
operation,  unless  already  in  artiado  mortis. 

10.  It  is  not  necessary  to  make  a large  incision, 
excepting  in  cases  in  which  perityphlitic  abscess 
is  known  to  exist,  which  is  rarely  the  case  in 
children.  If  perityphlitic  abscess  exist  and  is 
recognized  before  operation,  the  incision  should 
be  made  at  the  most  favorable  point,  which  in  the 
majority  of  cases  is  the  typical  line  for  ligation 
of  the  common  iliac,  as  pointed  out  by  Murphy 
and  Lee.  In  by  far  the  majority  of  cases  in  chil- 
dren a simple  median  exploratory  incision,  wdth 
flushing  of  the  abdominal  cavit}',  is  sufiicient. 


Note. — The  discussion  following  the  reading  of  this  paper  sug- 
gested to  me  the  possibility  of  my  views  being  misinterpreted.  I 
do  not  condemn  the  judicious  use  of  opium,  nor  would  I recom- 
mend operation  in  all  cases  of  peritonitis.  My  paper  bears  di- 
rectly upon  fulminant  attacks,  and  those  which,  although  less  acute, 
are  resistant  to  ordinary  measures  of  treatment. 


A STUDY  OF  A SERIES  OF  DEGENERATE  AND 
CRIMINAL  CRANIA. 

Presented  before  the  Chicago  Medical  Society,  April  so,  i8gt. 

It  is  my  fortune  to  be  able  to  present  to  the  So- 
ciety a series  of  specimens  illustrative  of  the  aber- 
rant types  and  asymmetry  found  in  degenerate 
skulls,  and  especially  those  of  criminals.  These 
specimens  are  especially  interesting  from  the  fact 
that  they  have  not  been  selected  from  among  a large 
number,  but  have  been  picked  up  here  and  there  by 
non-scientists,  solely  for  their  morbid  and  historic  in- 
terest, having  subsequently  fallen  into  my  hands 
quite  by  accident.  It  is  worthy  of  comment  that 
even  the  remarkable  series  depicted  in  Lombroso’s 


Fig.  1 — Front  View  of  Extreme  Dolicho-cephalic  Cranium. 
Atlas  does  not  present  such  markedly  aberrant 
types  as  this  comparatively  small  series  of  studies; 


66 


indeed,  a search  among  several  thousand  skulls 
would  not  be  apt  to  bring  to  light  such  peculiar 
types  of  conformation  as  the  crania  which  we  pre- 
sent. The  illustrations  are  from  photographs  and 
are  exceptionally  accurate. 

The  specimen  first  to  be  described  is  one  of  the 
most  interesting  crania  which  I have  had  the  privi- 
lege of  studying.  The  subject  was  a negro  crimi- 
nal of  the  petty  class,  who  spent  most  of  his  time  in 
correctionary  institutions.  As  might  be  inferred 
from  the  extremely  degenerate  type  of  cranial  de- 
velopment which  is  here  exhibited,  he  was  of  a very 
low  grade  of  intelligence.  After  a very  precarious 
existence  this  negro  committed  suicide. 

In  viewing  this  skull  from  the  front,  one  is  a 
once  struck  by  the  immensely  powerful  maxillar, 
and  malar  development  as  contrasted  with  the  re- 
mainder of  the  cranium.  The  orbits  are  relatively 
very  capacious.  The  superior  maxilla  is  relatively 
poorly  developed,  at  least  as  compared  with  the 
lower  jaw.  Rarely  indeed,  is  such  an  inferior 
frontal  development  found  associated  with  such  a 
pronounced  facial  development. 

As  will  be  seen  in  connection  with  the  specimen 
of  brachy-cephalic  degeneracy  shown  in  Figs.  21, 
22,  23  the  frontal  development  in  this  narrow  type 
of  skull  may  be  vastly  better  than  some  specimens 
with  a decided  tendency  to  the  brachy-cephalic  type. 
The  skull  at  present  under  consideration  is  the  most 
marked  specimen  of  the  dolicho-cephalic  cranium 
which  I have  seen.  As  the  cephalic  index  in  this 
case  is  59.9,  the  extreme  variation  according  to 
Isaac  Taylor  and  others  being  from  58  to  98,  the 
extreme  type  of  this  skull  is  at  once  obvious. 


6; 


Fig.  2 — -Lateral  View  of  Extreme  Dolicho-cephalic  Skull. 

On  viewing  this  skull  laterally,  its  strong  similarity 
to  the  anthropoids  is  very  striking.  Thisis  especially 
marked  with  respect  to  the  development  of  the  mas- 
toids  and  the  occipital  protuberance;  the  position  of 
the  latter  is  quite  an  anomalous  one,  and  the  occipi- 
tal bone  is  almost  horizontal.  Despite  its  extraor- 
dinary development,  the  occipital  bone  is  relatively 
small,  both  transversely  and  in  its  vertical  measure- 
ment. The  distance  from  the  posterior  border  of 
the  foramen  magnum  to  the  superior  occipital  angle 
is  only  103  m.m. 

On  contrasting  this  with  any  of  the  other  crania  of 
the  series,  the  relative  shortness  of  the  occiput  is  very 
noticeable.  For  example.  Fig.  10,  which  is  a rather 
small  specimem,  distinguished  rather  by  the  symme- 
try than  the  extent  of  its  development,  shows  an  oc- 
ciput measuring  130  m.m.  from  the  foramen  mag- 
num to  the  superior  angle  of  the  occipital  bone. 


68 


Fig.  3. 

Fig.  3 shows  the  inferior  surface  of  this  dolicho- 
cephalic specimen,  and  brings  out  the  massive  devel- 
opment of  the  processes  and  muscular  attachments 
at  the  base  of  the  skull.  It  is  evident  that  the  mus- 
cles of  the  neck  in  this  case  were  immensely  power- 
ful, a sine  qua  non  where  the  leverage  for  muscular 
action  is  so  short  as  in  this  particular  occiput.  The 
facial  type  in  this  specimen,  is  markedly  prognathous 
as  regards  both  upper  and  lower  jaws. 

The  tout  ensemble  in  this  case  is  strongly  suggest- 
ive of  a reversion  to  the  anthropoid  tvpe,  which  is 
often  the  distinguishing  characteristic  of  the  degen- 
erate Ethiopian  type,  criminal  or  otherwise.  The 
following  are  the  measurements  of  this  exceedinglv 


interesting  cranium: 

Cephalic  index 59.9 

Circumference 4S-4  c. 

Anterior  demi-circumference . . . . ^ . 2 r.3  c. 

Posterior  demi-circumference 26.9  c. 

Bi-zygomatic  diameter 13.3  c. 

Longitudinal  diameter 196.5  m.m. 

Transverse  diameter 122  m.m. 


Vertical  diameter  (vertex  to  foramen- 


6g 


magnum) 132  m.m. 

Occipitomental 241.5  m.m. 

Bi-frontal  diameter 95  m.m. 

Bi-mastoid  diameter 114  m.m. 

Over  vertex,  from  ear  to  ear 317  m.m. 

Ant.  bord.  foramen  mag.  to  sup.  occip- 
ital angle 103  m.m. 


The  excessive  development  of  the  jaws  and  alve- 
olar processes  in  this  specimen,  are  such  as  are  gen- 
erally observed  in  the  negro  races,  in  whom  the  jaws 
are  usually  well  developed  and  rarely  deformed. 
The  only  noticeable  feature  of  this  particular  speci- 
imen  is  a high  palatal,  vault. 


Fig.  4.  Skull  of  a Mongolian  suicide.  Brachv-cephalic. 

The  next  specimen  is  not  especially  noteworthy 
from  the  standpoint  of  degeneracy,  being  interesting 
chiefly  on  account  of  its  peculiar  history,  and  its  ex- 
ceedingly fine  development.  It  is,  however,  an  ex- 
cellent illustration  of  the  brachv-cephalic  cranial 
type. 


70 


The  subject  was  a Chinese  cigar-maker  of  Chica- 
go, who  is  remembered  to  have  been  thoroughly  civ- 
ilized and  quite  prosperous.  Ph^^sicall}',  he  was  a 
fine,  well  developed  and  handsome  fellow.  He 
became  engaged  to  a white  girl,  whose  Mongolian 
affinity  weakened  at  the  last  moment,  and  this,  prev- 
ing  upon  his  mind,  impelled  our  Mongolian  friend  to 
shoot  himself.  This  was  noteworthy,  as  this  subject 
was  the  first  Chinaman  in  America  to  commit  sui- 
cide, and  there  has  been  but  one  since,  as  far  as  I can 
learn.  The  peculiar  religious  belief  of  the  Chinese, 
e.xplains  the  rarity  of  suicides  among  those  in  Amer- 
ica, suicides  being  frequent  in  their  native  land. 

The  contrast  between  the  negro  skull.  Fig.  i,  and 
Fig.  4 is  veiy  striking,  and  obvious  to  the  most 
careless  observer.  A front  view  of  this  specimen 
.show's  a splendid  development  of  the  jaws  and 
teeth.  I have  never  seen  a finer  and  more  regular 
set  of  teeth  than  this.  Like  the  negro  race,  the 
Chinese  is  characterized  bv  well-formed  and  strong 
jaws  and  teeth. 


Fig.  5. — Skull  of  Mongolian  suicide.  Brachy-cephalic. 


71 


The  characteristic  excessive  development  of  the 
facial  and  jaw  bones  among  the  Chinese  is  well 
shown  by  a lateral  view  of  this  skull.  The  dispro- 
portionate development  of  the  face  and  jaws  in  this 
intance  is,  however,  much  above  the  average  Mon- 
golian skull.  By  comparing  the  two  views  the 
brachy-cephalic  tvpe  of  the  cranium  is  readily  ob- 
served. By  comparing  tbe  views  of  this  cranium 
with  those  of  the  negro  shown  in  Figs,  i and  2 one 
may  observe  the  wide  difference  between  the  ex- 
treme types  of  high  and  low  cranial  indices.  This 
is  nowhere  better  shown  than  by  a comparison  of 
marked  Ethiopian  and  Mongolian  types. 

On  examination  of  the  crania  of  the  more  degener- 
ate types  among  the  Chinese  it  will  be  found  that 
the  tendency  is  toward  a high  cranial  index.  The 
tendency  of  the  degenerate  types  of  a brachy-ce- 
phalic race  to  become  more  brach3^-cephalic,  and  that 
of  a dolicho-cephalic  race  to  become  more  dolicho- 
cephalic is  peculiar,  but  is  borne  out  as  far  as  my 
opportunities  for  study  have  permitted  me  to  ob- 
serve. 

Aside  from  a change  in  the  cranial  index  there 
are  seen,  among  negroes  particularly,  many  pecu- 
liar aberrations  of  form,  one  of  which  is  shown  in 
Fig.  1 6.  The  palatal  arch  in  this  Mongolian  speci- 
men is  high,  and  the  alveolar  processes  excessively 
developed.  The  measurements  of  this  skull  are: 


Index 83.9 

Circumference 50-6  c. 

Anterior  demi-circumference 29.4  c. 

Posterior  demi  circumference 21.2  c. 

Longitudinal  diameter 174  m.m. 

Transverse  diameter 149  m.m. 

Vertical  diameter 145  m.m. 

Bi-mastoid  diameter 127  m.m. 


72 


Bi-frontal  diameter pdm.m. 

Foramen  magnum  to  superior  occipital 

angle 139  m. 

The  next  specimen  presents  some  extraordinary 
features.  It  is  the  skull  of  a celebrated  negro  panel- 
worker,  confidence  operator  and  desperado,  who,  at 
the  time  of  his  death,  was  the  consort  of  a notorious 
courtesan  who  flourished  in  Chicago  some  years 
ago. 


Fig.  C. — Negro  Panel-worker.  DoHcho-cephalic. 

This  individual,  after  some  years  dalliance  with 
the  law,  without  especial  harm  to  himself,  was  finally 
knifed  in  a brawl.  A front  view  of  the  cranium 
shows  the  ordinary  and  characteristic  negro  facial 
type,  with  the  exception,  perhaps,  that  the  bones  are 
exceptionally  massive  and  well-developed.  Unfortu- 
nately the  inferior  maxilla  is  absent,  a fact  which  I 
greatly  deplore,  as  the  general  cranial  development 
suggests  to  me  the  probability  that  the  missing  part 
presented  some  ver}'  interesting  features  for  consid- 
eration. A lateral  view  of  this  cranium  shows  the 
ordinary  dolicho-cephalic  negro  t3^pe.  The  cranial 
index  is  low,  being  72.1.  A comparison  with  Fig. 


73 


I,  however,  shows  the  extreme  degeneracy  of  type 
in  the  latter  to  great  advantage. 


Fig.  7. — Negro  panel-worker.  Dolicho-cephalic. 

A view  of  this  skull  (Fig.  7),  after  a section  of 
the  calvarium  has  been  removed,  shows  its  most 
interesting  features.  Skulls  of  such  extreme  thick- 
ne.ss,  even  among  negroes,  are  rarely  met  with. 
The  consistency  of  the  bone  in  this  cranium  is  very 
dense  and  hard,  and  traditionally  this  negro,  while 
alive,  was  noted  for  his  butting  propensities.  Vio- 
lent contact  with  such  a skull  would  be  apt  to 
damage  the  fist  of  a Sulivan.  Indeed,  it  is  said  that 
this  fellow  rather  enjoyed  the  impact  of  a police- 
man’s club. 

I will  state  at  this  point  that  we  are  of  the  opinion 
that  the  massiveness  of  bony  development  in  this 
case  is  not  due  to  disease.  The  general  character 
of  the  overgrowth,  and  the  consistency  of  the  bone, 
would  seem  to  support  this  view.  Syphilis  may 
produce  thickening  of  the  cranial  bones,  as  some 


74 


of  Virchow’s  specimens  show,  but  syphilitic  bone 
does  not  present  the  characters  and  uniformity 
present  in  this  case. 

At  the  densest  part  of  the  calvarium  this  speci- 
men measured  13  m.m.  in  thickness,  its  average 
thickness  being  ii  m.m.  A comparison  with  Fig.  9 
readily  shows  how  phenomenal  the  osseous  develop- 


ment in  this  case  is.  The  cranial  measurements  are : 

Cephalic  index 71.1 

Circumference 47.8  c. 

Anterior  demi-circumference 25.4  c. 

Posterior  demi-circumference 22.4  c. 

Longitudinal  diameter i8i-5  m.m. 

Transverse  diameter 131  m.m. 

Vertical  diameter  (vertex  to  foramen 

magnum) 128  m.m. 

Bi-frontal  diameter 95  m.m. 

Bi-mastoid  diameter 113  m.m. 

Bi- zygomatic  diameter 126  m.m. 

Anterior  border  foramen  magnum  to  sup. 

occip  angle 1 17  m.m. 


The  upper  jaw  and  alveolar  process  in  this  skull 
is  well  developed,  the  only  peculiarity  being  a low 
palatal  vault. 


Fig.  8. — Skull  of  prostitute.  Dolicho-cephalic. 


75 


Fig.  8 shows  the  skull  of  a once  notorious  mem- 
ber of  the  Chicago  demi-monde.  She  was  a very 
tall  woman,  of  mixed  Indian  and  white  blood.  The 
cephalic  index  shows  what  might  be  inferred  from 
the  appearance  of  the  cuts — a decided  dolicho- 
cephalic type,  and  a peculiar  outline.  This  speci- 
men is  the  most  symmetrically  developed  of  the 
series,  with  the  exception  of  the  Sioux  squaw  next 
to  be  described,  and  whether  coincidental  or  not,  the 
fact  remains  that  this  subject  presented  a higher 
type  of  intellectuality  while  living  than  any  of  the 
other  subjects  embraced  in  this  essay.  The  skull 
is  nevertheless  of  a degenerate  type,  as  shown  by 
its  extreme  tenuity,  and  its  markedly  dolicho-ceph- 
alic  index. 

Fig.  9 shows  the  extreme  thinness  of  the  cal- 
varium, which  was  at  the  point  of  section  only  3 
m.m.  in  thickness.  A striking  feature  of  this  skull 
is  its  freedom  from  prominences,  its  surface  being 
uniformly  smooth  and  rounded.  In  this  respect  the 
specimen  differs  greatly  from  another  cranium  of  a 
prostitute  in  the  same  series  which  I have  examined, 
but  of  which  unfortunately  I have  no  illustra- 
tions. In  this  case  there  was  an  excessive  develop- 
ment of  the  occipital  bone,  the  enlargement  being 
symetrical  and  most  marked  upon  the  left  of  the 
median  line.  The  right  parietal  eminence  was  ex- 
cessively and  ilisproportionately  developed.  The 
cranial  index  was  markedly  dolicho-cephalic. 

The  principal  measurements  of  the  scull  at  present 


under  consideration  are: 

Cephalic  index 67.09 

Circumference c. 

Anterior  demi-circumference 22.9  c. 

Posterior  demi-circumference 27.3  c. 

Longitudinal  diameter 190  m.m. 


76 


Transverse  diameter i30-5  m.m. 

Vertical  diameter 128  m.m. 

Bi-£rontal  diameter 88.5  m.m. 

Bi-mastoid  diameter 71  m.m. 

Bi-zygomalic  diameter 130  m.m. 

Anterior  border  foramen  magnum  to  ant. 

sup.  occipital  angle 116  m.m. 

The  jaw  in  the  case  is  poorly  developed  but  fairly 
well  formed.  In  regard  to  the  extreme  tenuity  of 


Fig.  9. — Skull  of  prostitute.  Dolicho-cephalic.  Calvarium 
partially  removed. 

the  skull,  1 do  not  believe  that  it  is  the  result  of 
pathological  change.  The  general  lightness  of  the 
bones  and  the  symmetry  of  the  skull  are  not  con- 
sistent with  the  existence  of  such  bone  changes  as 
might  produce  absorption  and  thinning.  The 
markedly  dolicho-cephalic  type  of  this  skull  is  in- 
teresting in  view  of  the  strain  of  Indian  blood  in  the 
subject.  As  has  already  been  observed,  the  de- 
generate type  in  dolicho-cephalic  crania  is  in  the 
direction  of  a still  lower  index,  and  in  this  instance 


77 


the  admixture  of  Indian  blood  evidently  determined 
the  degenerative  type.  This  observation  would 
appear  to  be  contradicted  by  the  case  outlined  in 
Figs.  12,  13,  15.  In  this  case,  however,  there  was 
an  admixture  of  negro  and  Mexican  blood,  with  a 
resultant  degeneracy  of  form  in  general  as  well  as 
in  the  cephalic  index.  This  case,  in  fact,  partakes 
in  some  respects  of  the  character  of  a teratological 
rather  than  an  atavistic  type  -per  se — at  least  as  far 
as  the  facial  development  is  concerned. 

A comparison  of  the  prostitute’s  skull  with  the 
female  Indian  type  next  presented  shows  a marked 
difference  in  the  cranial  index,  the  disparity  being 
7.07.  Even  the  negro  in  Fig.  6 is  less  dolicho- 
cephalic than  this  specimen. 


Fig.  10.  Skull  of  .Sioux  Squaw.  Dolicho-cephalic. 

The  next  specimen  is  the  cranium  of  a full-blood 
squaw  of  the  Uncpapa  Sioux,  who  was  the  wife  of 
one  of  the  leading  malcontents  in  the  recent  Indian 
outbreak,  and  consequently  of  the  better  type  of 
Indian  development. 

This  specimen  is  exceptionally  symetrical  and 


78 


moderately  dolicho-cephalic.  inside  from  points  of 
contrast,  there  is  little  of  interest  to  be  said  of  it  in 
connection  with  the  present  series.  The  subject 
was  as  intelligent  as  the  better  class  of  her  people 
average,  and  there  is  nothing  to  be  said  regarding 
her  from  a standpoint.  Indeed,  as  the  saying  goes, 
the  shoe  might  be  on  the  other  foot,  as  the  Indian 
estimate  of  the  Caucasian  grave-robber  is  not  a high 
one,  as  evidenced  by  his  treatment  of  the  desecrator 
of  the  Indian  burial-places  when  the  latter  happens 
to  be  caught.  However,  as  my  connection  with  the 
aforesaid  desecration  is  very  remote,  I trust  that  my 
red  brother  will  extend  his  forgiveness. 


Fig.  11. — ^Skull  ofSiou.K  Squaw.  Dolicho-cephalic. 

Fig.  II  shows  the  same  skull  in  lateral  view.  Its 
symmetrical  outline  is  quite  evident.  The  measure- 


ments are  as  follows: 

Cephalic  index 74-^6 

Circumferential.  51.2  c. 

Anterior  demi-circumference 26.6  c. 

Posterior  demi-circumference 23.8  c. 

Longitudinal  diameter 161  m.m. 

Transverse  diameter 152  m.m. 

Vertical  diameter 140  m.m. 


79 


Over  vertex  from  ear  to  ear,  318  m.m. 

Occipital  protub.  to  root  of  nose 293  m.m. 

Bi-mastoid  diameter 121.5  m.m. 

Bi-frontal  diameter 96  m.m. 

Anterior  border  foramen  magnum  to  su- 
perior occipital  angle 130  m.m. 


The  superior  maxilla  presents  arrested  develop- 
ment. The  vault  is  of  medium  height,  and  the 
alveolar  processes  well-developed.  It  will  be  found 
that  in  the  Indian,  as  in  all  primitive  races,  a well 
formed  palate  and  regular  teeth  are  the  rule.  It 
would  be  interesting,  at  some  future  time,  to  study 
the  effects  of  civilization  of  the  Indian  in  this  re- 
gard. 

The  next  cranium  which  I will  describe  is  the 
most  remarkable  of  the  series,  and  in  many  respects 
presents  phenomenal  characters.  (Figs.  12  and 

^3-) 


Figs.  13  and  13.— Half-breed  Mexican  and  Negro.  Brachv- 
cephalic. 


8o 


The  subject  was  a half-breed  Mexican  and  negro, 
who  had  left  Mexico — his  native  country — for  the 
good  of  his  compatriots.  While  he  had  never  dis- 
tinguished himself  by  any  startling  act  of  criminality 
and  had  managed  to  keep  himself  out  of  the  clutches 
of  the  law,  he  was  identified  with  the  petty  criminal 
class  which  forms  a prominent  portion  of  all  social 
systems,  and  with  which  Mexico  is  especially'  in- 
fested. He  finally  died  in  a public  hospital,  as  a re- 
sult of  some  acute  disease  with  cerebral  complica- 
tions. The  general  physique  of  this  man  was  very- 
fair,  although  he  presented  a generally  overgrown 
and  loose-jointed  appearance.  When  alive,  he  was 
a very'  peculiar  looking  specimen  indeed,  the  dome- 
shaped appearance  of  his  cranium  being  exaggerated 
by  a luxuriant  crop  of  kinky  wool,  several  inches  in 
length,  that  stood  straight  out  from  his  head.  From 
a mental  standpoint,  he  was  up  to  the  average  of  the 
negro  race,  but  morally  speaking,  he  was  decidedly 
degenerate.  One  of  his  prominent  characteristics 
was  a very  irritable  and  irascible  temper. 

This  cranium,  as  is  well  shown  in  the  appended 
illustrations,  is  most  markedly' brachy-cephalic;  in- 
deed, its  circumferential  outline  is  almost  perfectly 
round,  its  longitudinal  and  transverse  diameters  being 
nearly  equal.  The  term  dome-shaped  is  as  nearly' 
accurate  as  possible  from  a descriptwe  standpoint. 
It  is  a singular  fact  that  the  degenerate  type  of  the 
x\frican  skull  often  presents  the  oxy-cephalic  or 
rafter-headed  type,  even  when  the  dolicho-cephal- 
ous  index  is  pronounced.  These  rafter  heads  are 
often  seen. 

The  skull  at  present  under  consideration  is,  as  al- 
ready remarked,  a distinctive  dome  shape,  which 
corresponds  not  at  all  with  the  rafter  head. 

The  peculiar  conformation  in  this  case  is  evi- 


8i 


Fig.  14 — Outline  of  Ancient  Peruvian  Skull  Mechanically 
Deformed. 

dently  not  the  result  of  pathological  conditions  or 
mechanical  pressure.  The  vault  of  the  cranium  is 
quite  symmetrically  developed,  although  the  base  of 
the  skull  is  decidedly  asymmetrical,  as  will  shortly 
be  shown.  I know  of  no  mechanical  means 
which  might  have  caused  the  peculiar  dome-like 
form  of  this  specimen,  nor  have  I been  able  to  find 
mechanically  deformed  crania  of  a similar  type. 
Such  deformities  as  those  presented  by  the  Chinook 
or  Flat-head  Indians  are  quite  familiar  types  of 
skulls  mechanically  deformed.  Certain  specimens 
found  in  ancient  Peruvian  graves  are  almost  pre- 
cisely identical  with  the  characteristic  Chinook  type, 
and  show  a probably  common  origin  of  the  two 
races.  This  type  is  fairly  well  shown  by  the  con- 
ventional outline  of  Fig.  14. 

There  are  several  interesting  features  in  connec- 
tion with  the  skull  under  consideration : One  of  the 

most  striking  is  the  extreme  shallowness  of  the 
orbits.  This  is  well  shown  by  comparison  with 
some  of  the  other  types  already  described,  the 
measurements  being  one  and  three-quarter  inches 
from  the  upper  margin  of  the  orbit  to  the  optic  for- 


82 


amen,  while  in  the  Indian  and  negro  skulls  in  this 
series  the  orbits  measure  two  inches  in  depth.  The 
outer  walls  of  the  orbits  encroach  upon  the  cavities, 
giving  a still  more  marked  appearance  of  shallow- 
ness. 

The  inferior  maxilla  also  presents  some  peculiar- 
ities: The  coronoid  processes  are  very  small  and 

short,  the  body  long,  and  the  angles  veiy  oblique. 
The  anterior  alveolar  process  is  excessively  de- 
veloped. The  same  is  true  of  the  alveolar  process 
of  the  superior  maxilla,  it  being  so  situated  on  the 
outer  surface  of  the  jaw  that  the  teeth  were  neces- 
saril}’  tipped  in  to  facilitate  occlusion  with  the  lower 
teeth.  The  central  incisors  were  evidently  lost  in 
early  life,  the  alveolus  being  absorbed  and  the 
border  of  the  jaw  only  one-eighth  of  an  inch  in 
thickness  at  this  point.  The  palatal  vault  is  very 
low,  and  the  general  development  of  the  jaws  im- 
perfect. 

There  is  a marked  deflection  of  the  vomer  and 
ossas  nasi,  evidently  of  non-traumatic  origin,  and 
due  to  excessive  development  of  the  osseous  and 
cartilaginous  structures  of  the  septum  nasi.  The 
nasal  spine  is  enormously  developed.  The  cranial 
index  in  this  case  is  extraordinarily  high,  being 
slightly  above  the  maximum  given  b}^  most  anthro- 
pologists. The  tj'pe  is  as  marked  in  the  direction 
of  a brachy-cephalic  index  as  is  Fig.  i in  the  direc- 
tion of  a low  or  dolicho-cephalous  index. 

Fig.  15  shows  the  inferior  surface  of  the  skull 
under  consideration.  A glance  suffices  to  show  its 
remarkable  asymmetiy.  The  foramen  magnum  is 
almost  entirely  to  the  left  of  the  median  line.  A 
line  drawn  through  the  center  of  the  foramen 
traverses  the  median  line  of  this  surface  at  an  an^le 

O 

of  about  forty-five  degress.  The  center  of  the  an- 


83 


terior  border  of  the  foramen  is  situated  at  76.5  m.m. 
from  the  left,  and  58  m.m.  from  the  right  mastoid. 
The  center  of  the  posterior  border  of  the  foramen 
is  64  m.m.  and  6r  m.m.  from  the  left  and  right 
mastoids  respectively.  The  margin  of  the  foramen 
is  extremely  thin,  and  the  occipital  ridges  very 
prominent.  Measurements  of  this  skull  are: 


Cephalic  index 98.  r 

Circumference 46.5  c. 

Anterior  demi-circumference 22.6  c. 

Posterior  demi-circumference 23.9  c. 

Longitudinal  diameter 146  m.m. 

Transverse  diameter 143  m.m. 

Vertical  diameter 148.5  m.m. 

Root  of  nose  to  occipital  protuberance . .313  m.m. 
Anterior  border  foramen  mag.  to  sup. 

occ.  angle . . 91  m.m. 

Bi-mastoid  diameter 115  m.m. 

Occipito-mental  diameter 248.5  m.m. 

Bi-frontal  diameter.  . . . 95  m.m. 

Bi-zygomatic  diameter i33-5  rn.m. 

Over  vertex  from  ear  to  ear 350  m.m. 


On  comparing  the  longitudinal,  vertical  and  trans- 
verse diameters  of  this  remarkable  skull  with  those 
of  some  of  the  others  of  the  series,  the  relatively 
great  height  of  this  dome-like  cranium  is  made  very 
apparent.  Thus  the  diameters  are : 


Trans.  Long.  Vert. 

Fig.  1 122  m m.  196.5  132  m.m. 

Fig.  4 146  m.m.  174  m.m.  145  m.m. 

Fig.  6 131  m.m.  181  m.m.  128  m.m. 

Fig.  8 I30-S  m.m.  190  m.m.  128  m.m. 

Fig.  10 152  m.m.  161  m.m.  140  m.m. 

Fig.  19 ^40-5  m.m.  180  m.m.  136.5  m.m. 

Fig.  21 149  m.m.  168  m.m.  118  m.m. 


Those  of  the  specimen  under  consideration  being 


84 


Fig.  15. — Inferior  Surface  of  Half-breed  Cranium. 

Trans.  143  m.m.,  Long.  146  m.m.  and  Vertical 
148.5  m.m.,  a comparison  with  Fig.  21  is  especialh' 
interesting. 

While  making  some  observations  at  the  Joliet 
penitentiary  I discovered  an  example  of  the  dome- 
shaped brachjr-cephalic  cranium  which  strongly  re- 
sembles the  extraordinary  specimen  just  described. 

This  subject  (Figs.  16  and  17)  is  a mulatto  about 
twenty-three  years  of  age,  who  is  doing  time  for 
attempted  murder.  He  is  a surly,  truculent  fellow, 
of  a low  grade  of  intelligence,  and  inclined  to  be  un- 
ruly. He  is  at  present  suffering  from  a mild  tvpe 
of  S}fphilis.  Tbe  form  of  the  cranium  is  well 
worthy  of  remark,  the  more  especially  as  it  so  near- 
ly approximates  the  type  shown  in  Figs.  12  and  13. 

The  facial  bones,  jaws  and  teeth  in  this  case  were 
extremely  well  developed,  and  the  palatal  vault 
normal.  There  was  no  history  of  mechanical  com- 
pression, and  as  the  subject  was  born  in  Tennessee 
such  a cause  is  improbable,  if  not  impossible.  The 
measurements  were  not  complete.  As  far  as  taken 
they  were: 


85 


Fig.  16. Dome-shaped  cranium;  mulatto.  Brachj-cephalic. 

Cephalic  index 76-7 

Root  of  nose  to  occipital  protuberance 

over  vertex 39.5  c. 

Transverse  diameter 145  m.m. 

Longitudinal  diameter 191  m.m. 

Circumferential S^-S  c. 

Occipito-frontal  diameter 59  m.m. 

Occipito-mental  diameter 28.5  m.m. 

The  dome-like  form  of  this  cranium  will  be  more 
evident  on  comparison  of  the  two  principal  measure- 
ments with  those  of  a skull  of  average  development. 
A comparison  was  made  with  that  of  one  of  the 
white  orderlies  in  the  prison  hospital,  a man  of  fine 
physique  and  good  cranial  development.  It  was 
found  that  while  the  measurement  over  the  vertex 
was  the  same  as  that  of  the  negro,  39.5c-,  the  cir- 
cumferential measurement  was  58.5c. 


86 


The  next  specimen  (Figs.  i8,  19,  20)  is  the  skull 
of  a noted  Western  criminal  and  desperado,  who 
was  lynched  for  train-wrecking  in  Wyoming  a num- 
ber of  years  ago.  The  conduct  of  this  man  during 
the  progress  of  the  lynching  s*'ampedhim  as  a bravo 
of  the  most  hardened  type.  An  attempt  was  made 
to  induce  him  to  relate  the  particulars  of  a murder 
in  which  he  had  participated,  the  wife  of  the  mur- 
dered man  being  present  at  the  hanging,  and  anx- 
ious to  learn  the  details  of  her  husband’s  death.  To 
the  persuasive  efforts  of  the  “ regulators,”  and  the 
tears  and  entreaties  of  the  widow  of  his  victim,  he 
replied:  “D — n it,  you’ll  hang  me  if  I tell,  and 


Fig.  17,— Dome-shaped  cranium;  mulatto.  Brachj-cephalic. 

vou’ll  hang  me  if  I don’t.  So  here  goes,”  saying 
which  he  deliberately  kicked  the  barrel  upon  which 


87 


he  was  standing  out  from  under  himself  and  thus 
saved  his  self-appointed  executioners  all  further 
trouble. 


Pip  Skull  of  Western  desperado.  Sub-dolicho-cephalic. 

This  specimen  is  sub-dolicho-cephalic  and  chiefly 
characterized  by  its  marked  asymmetry. 


PiQ.  19. Skull  of  Western  desperado.  Sub-dolicho-cephalic 

The  occipital  region  in  this  cranium  is  excessively 
developed,  prominent  and  bulging,  being  ^ especially 
prominent  on  the  left  of  the  median  line.  The 
occipital  protuberance  is  situated  about  8 m.m.  to 


88 


the  left.  The  parietal  eminences  are  very  asymmet- 
rical, the  right  being  very  prominent  and  of  irregu- 
lar contour.  The  palatal  vault  is  of  medium  height, 


the  teeth  regular  and  the  maxilla  well  developed. 
The  measurements  are: 

Cephalic  index 77-8 

Circumference 50.3  c. 

Anterior  demi-circumference  21.9  c. 

Posterior  demi-circumference 28.6  c. 

Transverse  diameter 140.5  m.m. 

Longitudinal  diameter 180  m.m. 

Bi-frontal  diameter 105  m.m. 

Bi-mastoid  diameter 126  m.m. 

Bi-zygomatic  diameter 134  m.m. 

Root  of  nose  to  occipital  protuberance.  312  m.m. 

Over  vertex  between  auditor!  meati . . . . 327.5  m.m. 


Foramen  magnum  to  sup.  occipital  angle  128  m.m. 


Fig.  20. — Skull  of  Western  desperado.  Sub-dollcho-cephalic. 

Viewed  from  above  (Fig.  20),  this  cranium  shows 
a fairly  symmetrical  outline.  The  above  illustration 
is  used  for  the  purpose  of  comparison  with  Fig.  23. 


8p 


The  next  specimen  (Figs.  21,  22,  23)  is  by  far  the 
most  interesting  of  the  series  from  the  standard  of 
degeneracy,  and  is  certainly  the  most  markedly 
asymmetrical.  If  it  were  possible  to  conceive  of  a 
special  criminal  type  of  cranium,  this  would  in  many 
respects  be  an  ideal  illustration.  The  subject  was  a 
noted  Western  desperado  and  train-wrecker,  who 
was  lynched  at  Carbon,  Wyoming,  back  in  ihe 
seventies,  for  an  attempt  to  wreck  a train  at  Medicine 
Bow.  In  this  attempt  he  was  assisted  by  the  in- 
dividual represented  in  Figs.  18,  19,  20. 

The  extremely  disproportionate  breadth  of  this 
cranium  is  well  shown  by  the  above  illustration.  The 
meagre  development  of  the  frontal  region  is  very 
noticeable.  On  viewing  this  skull  from  above,  the 
peculiar  twisted  appearance  which  may  be  observed 
in  connection  with  the  cranial  type  of  the  criminal  in 
general  will  be  observed.  The  orbits  are  relatively 
large,  and  the  face  as  a whole  of  a decidely  “ squatty” 
appearance.  The  absence  of  the  inferior  maxilla  is 
to  be  regretted, although,  considering  the  vicissitudes 
which  the  skull  has  experienced,  its  otherwise  per- 
fect state  of  preservation  is  rather  remarkable.  After 
the  lynching  of  this  gentleman  the  body  was  buried 
in  a hastily  improvised  and  shallow  grave,  from 
which  it  was  very  promptly  resurrected  by  those  scav- 
engers of  the  prairie,  the  coyotes.  The  skull  was 
finally  found  by  a railroad  employe,  and  subsequently 
used  as  a paper-weight  for  some  years. 

Judging  from  the  conformation  of  the  cranial  and 
facial  bones  the  lower  maxilla,  while  probably  well, 
or  perhaps  excessively  developed,  was  without  doubt 
asymmetrical.  The  relatively  defective  frontal  de- 
velopment of  this  skull  is  its  most  striking  feature 
when  viewed  in  its  anterior  outline,  and  is  best  shown 
by  comparison  with  Figs,  i,  2,  and  6.  In  the  former 


90 


Fig.  21. — Desperado  and  train-wrecker.  Extreme  Brachy-cephalj- 
the  extreme  breadth  is  122  m.m.,  and  the  extrem. 
length  196.5  m.m.,  while  the  frontal  breadthis  95  mm 
In  the  skull  under  consideration,  however,  althouge 
the  extreme  breadth  is  149  m.m.  and  the  extreme 
length  but  171  m.m.,  the  frontal  breadth  is  only  90 
m.m.  The  great  disproportioninthe  measurements 
is  at  once  obvions.  In  Fig.  6,  the  greatest  breadth 
is  131  m.m.,  and  the  greatest  length  181.5  m.m.,  yet 
the  transverse  frontal  diameter  is  95  m.m. 

The  disproportion  is  not  compensated  for  in  Fig. 
21  by  an  increased  longitudinal  development  of  the 
frontal  bone. 

The  twisted  appearance  of  this  skull  is  most  evi- 
dent on  comparison  of  the  parietal  eminences.  These 
are  very  prominent  on  both  sides,  the  left  being 
much  the  larger  of  the  two.  The  occipital  region  is 
greatly  deformed  and  exceptionally  prominent,  the 
bulging  being  most  marked  upon  the  left  of  the 
median  line.  The  asymmetry  of  development  is 
shown  by  a comparative  measurement  of  the  distance 
of  each  parietal  eminence  from  the  occipital  protub- 
erance. This  measures  on  the  right  side  132  m.m., 


and  on  the  left  only  119  in.m.  The  squatty,  animal- 
like type  of  this  cranium  is  shown  by  a comparison 
of  its  vertical  measurement  with  some  of  the  others 
of  the  series.  From  the  highest  point  at  the  vertex 
to  the  anterior  border  of  the  foramen  magnum,  the 
measurement  is  118  m.m.  That  of  Fig.  2,  which  is 
so  distinctively  anthropoid  in  its  development  andout- 
line,  the  vertical  measurement  is  132  m.m.;  of  Fig. 
5,  a symmetrical  brachy-cephalic  type,  is  145  m.m.; 
of  Fig.  6,  1 18  m.m.;  of  Fig.  10,  140  m.m.;  of  Fig. 
13,  148.5  m.m.,  and  of  Fig.  19,  136.5  m.m.  A little 
study  of  these  measurements  will  show  the  extreme 


Fig.  22. — Desperado  and  Train-wrecker.  Brachy-cephalic. 

animality  of  type  in  this  cranium,  even  as  compared 
with  others  of  a pronounced  degeneracy  of  type. 

Viewed  from  above,  Fig.  23  shows  the  circum- 
ferential outline  of  this  specimen.  By  comparing 
the  quadrants  of  this  illustration,  the  pronounced 
asymmetry  of  development  is  easily  seen. 

The  superior  maxilla  in  this  skull  is  well  devel- 
oped, although  the  alveolar  process  shows  an  infer- 
ior development.  The  palatal  arch  is  exceedingly 
low.  The  left  superior  ma.xilla  is  much  smaller  than 


92 


the  right.  The  palatal  processes  show  great  asym- 
metry, the  right  being  i6  m.m.  and  the  left  but  5 
m.m.  in  breadth.  The  measurements  of  this  cranium 


are : 

Cephalic  index by.  13 

Circumferential 49  c. 

Anterior  demi-circumference 20.35 

Posterior demi-circumference 28.65 

Longitudinal  diameter 17 1 m.m. 

Transverse  diameter 149  m.m. 

Vertical  diameter 18S  m.m. 

Bi-frontal  diameter 90  m.m. 

Bi-mastoid 10S.5  m.m. 

Bi-zygomatic 132  mm. 

Vertical  circumference  from  ear  to  ear.  279  m.m. 

Center  of  left  parietal  prominence  to  oc- 
cipital protuberance 119  m.m. 

Center  of  right  parietal  prominence  to 

occipital  protuberance 132  m.m. 

Anterior  border  foramen  magnum  to  su- 
perior occipital  angle  128  m.m. 


93 


MATERIALISM  VERSUS  SENTIMENT  IN 
THE  STUDY  OF  THE  CAUSES  AND 
CORRECTION  OF  CRIME. 


Public  Address  before  the  Kentucky  State  Medical  Society, 
Henderson,  Ky.,  May  ii,  1890. 


When,  in  response  to  the  courteous  and  com- 
plimentary invitation  of  your  secretary,  I prom- 
ised to  deliver  an  address  upon  the  relation  of 
materialism  to  the  vice  problem,  I did  not  realize 
the  difficulty  of  presenting  views  of  a comprehen- 
sive character  within  the  time  allotted  me.  Since 
beginning  my  task,  however,  I have  found  that 
it  will  be  impossible  for  me  to  present  anything 
more  than  an  array  of  generalities.  These  gen- 
eralities, gleaned  from  an  extensive  range  of 
thought  upon  this  subject,  I trust  may  at  least 
serve  as  food  for  reflection. 

Some  years  ago  I published  in  the  Chicago 
Medical  Journal  and  Examiner  a contribution  en- 
titled, “The  Pathological  Causes  ofVice.’’  This 
was  based  upon  observations  of  the  criminal  class 
during  my  service  as  surgeon  at  the  Blackwell’s 
Island  Penitentiary,  and  in  other  metropolitan  in- 
stitutions. This  article,  while  well  received  by 
the  majority  of  my  friends  in  and  out  of  the  profes- 

29 


94 


Sion,  invoked  the  wrath  of  a few  orthodox  indi- 
viduals to  such  an  extent  that  I was  stimulated 
to  further  discussion  and  study  of  the  subject. 
Fanatical  opposition  is  sometimes  an  excellent 
evidence  that  our  work  is  based  upon  sound  prin- 
ciples. 

In  announcing  myself  as  a materialist  as  far  as 
the  study  of  vice  is  concerned,  I trust  that  my 
position  may  not  be  misinterpreted,  for  it  is  cer- 
tainly not  my  intention  to  detract  from  the  im- 
portance of  the  moral  law  in  its  relation  to  the 
production  and  repression  of  vice,  or  to  lessen  the 
elforts  of  the  moralist  in  his  attempts  to  oppose 
goodness  to  badness.  It-  is  the  function  of  the 
materialist  to  liberalize  the  existing  theories  re- 
garding the  causation  and  repression  of  vice  and  to 
reduce  the  subject  to  a scientific  and,  as  far  as  pos- 
sible, evolutionary  basis. 

The  study  of  the  causes  and  prevention  of  vice 
and  crime  in  their  various  phases  is  one  of  the  most 
important  and  practical  questions  of  the  age.  The 
varying  forms  of  violation  of  physical,  social, 
statutory,  and  moral  law,  which  are  included  un- 
der the  heads  of  vice  and  crime,  are  the  outcome 
of  certain  circumstances  of  environment  and 
laws  of  progression,  which  are,  and  have  ever 
been  present  and  operable  in  society;  in  all  social 
systems,  whether  of  high  or  low  degree  of  devel- 
opment, and  in  every  grade  of  civilization.  It  is 
obvious  therefore  that  a philosophical  study  of 
vice  is  a social  necessitj^,  quite  as  much  so  as  is 
the  study  of  morbid  conditions  of  our  physical 
bodies  resulting  from  aberrations  of  physiologfcal 
laws.  Indeed,  the  two  studies  are  more  or  less 
interdependent,  and  therefore  demand  the  interest 
of  the  physician  as  well  as  the  philosopher.  In 
my  opinion  it  is  to  the  physician,  and  not  to  the 
moralist  or  law- maker,  that  the  society  of  the  fut- 


95 


ure  is  to  look  for  measures  oi  repression  or  the 
better  correction  and  prevention  of  vice  and  crime. 
Our  knowledge  of  the  causes  and  methods  of  pre- 
vention of  crime  is  at  the  present  time  decidedly 
unsatisfactory  and  crude  from  a philosophical 
standpoint,  chiefly  because  the  science  of  statis- 
tics is  yet  in  its  infancy,  and  to  a great  extent  be- 
cause the  moralist  has  acted  as  an  obstructionist 
and  has  impeded  the  progress  of  those  who  have 
undertaken  to  reduce  the  question  to  a purely 
physio-philosophical  basis. 

I will  at  this  point  advance  the  proposition 
that  the  actions  of  man  are  governed  entirely  by 
the  state  of  society  in  which  they  occur.  Crimes 
are  the  result  of  precedent  circumstances;  they  are 
the  pictured  and  tangible  results  of  occult  influ- 
ences, past,  present  and  to  come,  i.  e. , they  are 
the  result  of  an  all-pervading,  invincible  and  ever- 
lasting law.  Criminal  acts  are  not  isolated  ex- 
periences with  no  necessary  antecedents  or  future 
repetitions. 

The  doctrine  of  free  will,  {i.  e.  of  individual 
responsibility),  is  so  simple  and  appeals  so  strong- 
ly to  the  self-esteem  and  sentiment  of  the  masses 
that  it  is  accepted  by  the  majority  of  individuals 
with  a faith  and  simplicity  that  prevails  on 
no  other  question  of  corresponding  magnitude. 
How  simple  and  satisfactory  it  is  for  us  to  say 
that  our  fellow-man  has  committed  a crime,  be- 
cause forsooth  he  is  less  holy  than  we!  This 
Pharisaical  sophistry  is  but  the  outcome  of  human 
egotism,  and  as  long  as  it  prevails  and  controls 
our  social,  moral  and  legal  efforts  at  repression, 
so  long  will  our  criminal  classes  flourish  and  mul- 
tiply. Indeed,  “he  who  does  not  advance  goes 
backward,”  and  our  social  system  is  apt  to  grow 
worse  instead  of  better.. 

It  is  hardly  necessary  to  go  into  details  regard- 


96 


ing  the  superficiality  of  the  prevalent  methods 
of  study  and  repression  of  crime.  It  is  so  appar- 
ent that  it  must  strike  the  most  casual  observer. 
Much  has  been  done  in  the  way  of  moral  and 
physical  persuasion,  but  very  little  indeed  in  the 
direction  of  philosophical  methods  of  the  study 
and  correction  of  causes.  As  civilization  has  ad- 
vanced and  theology  has  become  enlightened  in 
its  theory  and  methods,  a corresponding  improve- 
ment in  the  moral  tone  of  the  social  body  should 
be  expected.  Unfortunately,  however,  there  has 
been  no  improvement — as  far  as  statistics  ser\^e  to 
testify — which  is  sufficient  to  encourage  the  ef- 
forts of  the  moralist  to  any  great  extent.  The 
futility  of  moral  measures,  as  demonstrated  by 
past  experiences,  is  explicable  only  upon  the 
ground  that  there  is  something  more  than  free 
will  to  account  for  criminal  acts.  Free  will  is 
operable  only  in  the  case  of  individuals,  and  moral 
persuasion  affects  only  the  individual  and  inci- 
dentally the  circumstances  which  sway  the  voli- 
tion of  the  criminal.  It  accomplishes  little  or 
nothing  in  correcting  or  antagonizing  the  general 
law  underlying  the  production  of  the  criminal 
class.  By  analogical  reasoning  the  futility  of 
moral  means  of  repression  may  be  readily  shown. 
We  will  suppose,  for  example,  that  a certain  por- 
tion of  the  human  body  is  affected  by  disease  de- 
pendent to  a greater  or  less  extent  upon  a de- 
praved constitutional  condition.  Obviouslj’  meas- 
ures of  local  correction,  i.  e.  correction  of  the 
local  depravity  of  tissue,  although  useful  to  a 
certain  extent,  fail  of  their  object  unless  the  gen- 
eral and  constitutional  influences  which  tend  to 
enhance  the  local  trouble  are  recognized  and  cor- 
rected. The  individual  is  but  an  atom  of  the  so- 
cial fabric.  When  he  is  depraved,  logic  requires 
a search  for,  and  if  found  the  correction  of  the  mor- 


97 


bid  general  or  constitutional  influences  pervading 
social  body  which  bring  about  perversion  of 
thought  and  action  in  the  individual.  Moral  per- 
suasion is  but  a minor  consideration;  the  law  can- 
not cope  with  the  question,  and  punishment  is 
futile  because  these  influences  operate  upon  the 
isolated  integer  and  not  upon  the  law  of  causa- 
tion. Admitting  that  certain  criminals  are  so  by 
reason  of  structural  peculiarities,  the  inefiicacy  of 
preaching  is  at  once  explicable. 

That  criminality  is  the  resirlt  of  certain  causal 
influences  operating  by  a fixed  law  has  been  rec- 
ognized by  several  eminent  historical  and  statis- 
tical authorities.  Buckle  and  Quetelet  have  ad- 
vanced some  striking  arguments  bearing  upon  the 
influences  modifying  the  moral  conduct  of  the 
human  race.  It  would  appear  that  many  of  the 
actions  of  mankind  which  we  are  prone  to  attri- 
bute to  free  will  and  independent  action  upon  the 
part  of  the  individual,  are  really  the  result  of  a 
fixed  and  immutable  law  controlling  the  moral 
world,  almost  as  definite  and  arbitrary  as  the  laws 
controlling  the  physical  world.  As  compared 
with  this  law  the  independence,  i.  , free  will  of  the 
individual  and  the  local  circumstances  of  environ- 
ment in  operation  at  the  time  of  the  apparently 
volitionary  action,  are  of  but  little  moment,  and 
^are  but  accidents  in  the  chain  of  events.  It  has 
been  shown  by  the  statistics  of  Great  Britain  and 
France  that  there  is  a constant  proportion  main- 
tained in  the  ratio  of  criminal  acts  to  the  number 
of  population  in  those  countries. 

Rawson  says;  ^ “ No  greater  proof  can  be  given 
of  the  possibility  of  arriving  at  certain  constants 
with  regard  to  crime  than  the  fact  that  the  great- 
est variation  in  the  proportion  of  any  class  of 
criminals  at  the  same  period  of  life  during  a pe- 


I Inquiry  into  the  Statistics  of  Crime  in  England  and  Wales. 


98 

riod  of  three  years  has  not  exceeded  a half  of  one 
per  cent.” 

Quetelet  says:  “ In  everything  which  concerns 
crime  the  same  numbers  recur  with  a constancy 
which  cannot  be  mistaken.  This  is  the  case  even 
with  those  crimes  which  seem  quite  independent 
of  human  foresight — such,  for  instance,  as  mur- 
ders, which  are  generally  committed  after  quarrels 
arising  from  circumstances  apparently  casual. 
Nevertheless  we  know  from  experience  that  ever^’ 
year  there  takes  place  not  only  the  same  propor- 
tionate number  of  murders,  but  that  even  the 
very  instruments  with  which  they  are  committed 
are  employed  in  the  same  proportion.” 

Buckle  says:  ® ‘‘Suicide  is  merely  the  protec- 
tion of  the  general  condition  of  society;  the  indi- 
vidual’s volition  only  carries  into  effect  what  is 
the  necessary  consequence  of  preceding  circum- 
stances. In  a given  state  of  societj"  a certain 
number  of  persons  must  put  an  end  to  their  own 
lives.  This  is  the  general  law,  and  the  special 
question  as  to  who  shall  commit  the  crime  de- 
pends of  course  upon  special  laws  which  howev^er, 
in  their  total  sections  must  obe}^  the  large  social 
law  of  which  they  are  all  subordinates.  The 
power  of  the  larger  law  is  so  irresistible  that 
neither  the  love  of  life  nor  the  fear  of  another 
world  can  avail  anything  toward  even  checking 
its  operations.” 

Buckle  further  shows  by  statistics  that  notwith- 
standing the  var5dng  causes  of  suicide  which  exist 
in  society,  such  as  political  excitement,  want, 
mercantile  crises,  disappointments  in  love,  de- 
pression induced  by  disease,  etc.,  there  has  been 
in  London  a very  constant  average  of  suicides, 
the  average  having  been  during  five  years  240 


2 Sur  VHomme,  Paris,  1835. 

3 History  of  Civilization  in  England. 


99 


per  year.  The  variation  in  the  number  was  not 
very  great  in  proportion  to  the  number  of  popu- 
lation, running  from  213  to  266,  the  latter  num- 
ber being  attained  in  the  year  1846,  which  was 
distinguished  by  the  great  railway  panic.  At 
this  time  the  ratio  of  suicides  might  naturally  be 
expected  to  be  extremely  high,  but  as  a matter 
of  fact,  it  was  less  than  one-half  per  cent,  higher 
than  the  preceding  yeai.  Mechanical  laws  may 
be  disturbed  by  accidental  disturbances,  yet  they 
prevail;  so  it  is  with  the  moral  law. 

As  showing  how  the  regularity  in  the  course  of 
events  may  manifest  itself  in  the  most  trifling  de- 
tails of  every  day  life  one  of  Buckle’s  statements 
is  very  interesting.  It  is  not  infrequent  for  indi- 
viduals through  carelessness  to  drop  undirected 
letters  in  the  mail  box.  Such  an  oversight  might 
naturally  be  attributed  to  individual  carelessness, 
but  it  is  shown  by  statistics  that  in  London  and 
Paris,  due  allowance  being  made  for  varying  cir- 
cumstances, increased  population,  etc. , that  there 
is  practically  the  same  number  of  undirected  let- 
ters found  in  the  mail  every  year. 

It  is  generally  supposed  that  in  the  matter  of 
matrimony  the  individual  is  governed  by  freewill. 
Statistics  prove  that  there  is  a constant  variation 
in  the  proportion  of  marriages  corresponding  to 
the  rise  or  fall  of  the  price  of  food  products.  So 
it  may  be  seen  from  the  foregoing  that  as  far  as 
statistical  evidence  goes  we  may  well  believe  that 
“ there  is  a Divinity  that  shapes  our  ends,  rough 
hew  them  as  we  may.’ 

Leaving  the  question  of  a general  law  influenc- 
ing society  and  determining  with  unwavering  fi- 
delity the  occurrence  of  certain  acts  which  we 
term  criminal  or  vicions,  it  is  unquestionably  true 
that  there  are  certain  special  causes  in  operation. 
The  influence  of  heredity  is  so  well  recognized 


lOO 


that  any  remarks  in  that  connection  may  be  con- 
sidered trite;  it  would  however  be  impossible  to 
do  the  subject  justice  without  an  allusion  to  it. 
It  is  not  always  an  easy  matter  to  isolate  heredi- 
tary influences  from  others  of  a special  character 
which  operate  in  the  development  of  vice  and 
criminality,  but  there  are  certain  typical  cases 
upon  record  which  conclusively  prove  that  hered- 
itary impulses  to  breaches  of  social  ethics  are  a 
very  important  consideration  in  the  study  of  the 
causes  and  prevention  of  vice.  There  is  frequent- 
ly an  intimate  association  between  hereditary  de- 
fects of  a physical  character  and  those  manifesta- 
tions of  heredity  which  result  in  crime.  In  many 
instances  a special  act  of  criminality  can  be  di- 
rectly traced  to  certain  hereditary  or  perhaps  con- 
genital physical  aberrations.  The  powerful  in- 
fluence of  heredity  in  the  production  of  vice  and 
crime  is  not  so  manifest  in  this  country  as  in  some 
of  the  older  countries  of  the  world.  Its  influence 
is  not  so  dominant  among  the  higher  classes,  in 
countries  in  which  a Republican  form  of  govern- 
ment prevails  as  in  those  in  which  an  effete  mon- 
archial  and  aristocratic  system  of  control  exists. 
The  older  and  larger  the  city  the  more  pro- 
nounced its  viciousness.  Thus  it  is  to  London  we 
must  look  for  the  very  reflnements  of  vice  and 
crime.  The  expose  of  the  hideous  orgies  of  Cav- 
endish Square  followed  very  closely  upon  those 
sensational  murders  of  women  which  attracted  the 
attention  of  the  whole  world  to  the  great  metrop- 
olis. 

In  Dr.  Ireland’s  book,  “ A Blot  on  the  Brain,” 
we  have  evidence  collated  which  is  sufficient  to 
convince  any  thinking  man  that  the  aristocracy 
of  the  Old  World  is  hereditarily  rotten  to  the  core. 
My  hearers  may  perhaps  be  familiar  with  his  un- 
merciful handling  of  the  House  of  the  Romanoffs, 


loi 


in  which  his  statements  are  so  eminently  true 
that  the  sale  of  the  book  has  been  prohibited 
throughout  the  Russian  domain.  Not  that  the. 
aristocracy  per  se  are  more  liable  to  viciousness 
than  an}'  other  class  of  people  similarly  situated. 
Unbridled  license,  idleness  and  the  possession  of 
unlimited  resources,  when  taken  in  connection 
with  the  circumstance  of  consanguinity  or  in-breed- 
ing, are  enough  to  account  for  the  corruption  of 
the  dominant  element  in  European  society. 

That  actual  physical  aberrations  or  atypical 
conformations  of  structure  must  bear  a certain 
responsibility  for  the  development  of  the  criminal 
class  is  amply  shown  by  the  researches  of  Bene- 
dict and  Osier.  These  experimenters  have  shown 
quite  a constant  relation  between  atypical  cerebral 
development  and  criminality.  The  assertion  that 
criminals  and  a certain  class  of  insane  exhibit  a 
defective  or  aberrant  brain  development,  has  been 
the  conclusion  of  such  students  of  the  subject  as 
Corre,  Eombroso,  Mills,  Rousel-Marro,  Pavlosky, 
Varaglin,  Tenchini,  and  Badik.  To  be  sure  we 
must  take  into  consideration  the  naive  declara- 
tion of  Benedict  that  certain  of  these  cases  were 
collected  as  the  result  of  a priori  conviction  that 
the  criminal  is  an  individual  having  the  same  re- 
lation to  crime,  as  his  next  blood  kin,  the  epilep- 
tic, and  his* cousin,  the  idiot,  have  to  their  com- 
mon encephalo-pathic  condition.  Hackneyed  as 
the  illustration  may  be  there  is  as  yet  no  better 
exemplification  of  the  effects  of  heredity  than  that 
embraced  in  the  wonderful  tables  and  statistics  of 
the  immortal  Richard  Dugdale  in  his  history  of 
the  Jukes. 

Ribot,in  his  famouswork  on  Heredity, has  shown 
remarkable  examples  of  an  inherited  predilection 
not  only  for  crime  in  general,  but  of  certain  forms 
of  crime  and  vicious  impulses. 


102 

I perceive  that  my  paper  is  spinning  out  to  an 
unwarrantable  length,  and  I will  therefore  pre- 
sent as  briefly  as  possible  those  causes  which 
students  of  this  important  social  problem  should 
always  be  ready  to  recognize. 

1 . The  first  cause  is  that  occult  all-pervading  and 
remorseless  law  which  pervades  all  social  sys- 
tems. To  this  law  I would  apply  the  old  term  pre- 
destination, were  it  not  in  my  opinion  too  arbi- 
trary an  expression  and  likely  to  lay  me  liable  to 
the  impeachment  of  illiberality.  This  cause  has 
already  been  suflBciently  expatiated  upon.  There 
appears  to  be  an  occult  influence  of  an  epidemic 
character  affecting  chiefly  the  crimes  of  murder 
and  suicide.  This  is  so  trite  that  I would  scarce- 
ly mention  it  but  for  m}"  desire  for  completeness 
of  classification.  There  has  recently  occurred  in 
rapid  succession  in  numerous  large  cities  in  this 
country  a considerable  number  of  cases  of  wife 
murder  followed  by  suicide.  These  are  an  illus- 
tration of  a peculiar  kind  of  homicidal  mania  of 
an  apparently  epidemic  character  which  occurs 
now  and  then.  It  is  my  opinion,  and  in  this  I 
am  not  alone,  that  the  public  press  fosters  this 
epidemic  influence  by  its  blood-curdling  accounts 
of  such  cases.  It  is  a question  in  my  mind 
whether  the  complaisant  manner  in  which  the 
7ninuti(B  of  robberies  and  defalcations  *are  recited 
by  the  newspapers,  has  not  its  influence  in  pro- 
ducing crime. 

2.  Hereditary  impulse  independent  of  percep- 
tible physical  aberrations.  It  is  possible  that  habit, 
persisted  in  through  many  succeeding  generations, 
may  result  in  a faulty  power  of  reasoning,  which, 
although  not  characterized  b}’-  variations  in  phj's- 
ical  conformation,  may  yet  be  transmitted  through 
countless  generations. 


103 

3-  Defective  physique  and  imperfectly  devel- 
oped intellect,  hereditary  or  congenital. 

4.  Acquired  disease  lessening  the  moral  sense 
and  will  power.  Instances  of  this  kind  are  fa- 
miliar to  all  of  us.  Vicious  or  criminal  acts  per 
formed  under  the  influence  of  acute  delirium  or 
mania  and  due  to  various  diseases,  are  frequently 
met  with. 

5.  Injuries  to  the  brain.  This  cause  of  crime 
and  vice  is  a very  familiar  one,  especially  to  the 
alienist  and  neurologist. 

6.  Alcoholism.  To  this  cause  there  are  many 
who,  in  what  I consider  illiberality,  attribute 
nearly  if  not  quite  all  cases  of  criminality.  There 
is  no  question  but  that  alcoholism  is  a potent 
cause  of  crime,  but  there  are  thousands  of  cases  of 
criminal  acts  which  are  apparently  traceable  to  it, 
yet  in  which  the  influence  of  alcohol  is  secondary 
to  physical  causes  inherent  to  the  individual. 
There  were  certain  interesting  facts  brought  out 
by  the  recent  Congress  of  Alcoholism  in  Paris, 
which  illustrates  the  importance  of  the  study  oi 
the  relation  of  alcoholism  to  crime.  It  was  shown, 
for  example,  that  there  was  quite  a constant  rela- 
tion between  the  amount  of  alcohol  consumed  in 
various  social  systems  and  the  amount  of  crime. 
It  is  my  impression,  however,  from  a study  of 
the  statistics  developed  by  this  Congress  that  the 
survey  of  the  field  of  criminality  had  been  rather 
a narrow  one,  and  that  certain  collateral  elements 
in  the  causation  of  crime  had  failed  to  receive 
their  due  need  of  consideration.  Some  of  the 
studies  of  the  Congress  were  rather  interesting  in 
this  connection.  For  example,  it  was  shown 
that  in  Berne,  where  there  are  only  four  saloons 
per  thousand  of  inhabitants,  criminality  was  more 
prevalent  than  in  Zurich,  I’here  the  proportion  is 
12  to  the  thousand. 


7-  Vicious  example  and  surroundings — en- 
vironment. This  involves  the  question  of  crim- 
inal contagion,  which  is  very  important  in  con- 
nection with  our  own  defective  methods  of  correc- 
tion. The  herding  together  of  all  grades  of  crime 
is  one  of  the  most  pernicious  systems  that  could 
be  devised.  In  our  own  city  of  Chicago,  for  ex- 
ample, there  is  no  reformatory  for  young  lads,  and 
they  are  therefore  sent  to  the  Bridewell,  where 
they  eventually  become  contaminated  by  older 
criminals.  This  proceeding  is  as  rational  as 
would  be  the  sending  of  a case  of  sore  throat  to  a 
diphtheria  hospital.'* 

8.  Defective  education  and  consequent  imper- 
fect mental  discipline.  This  is  a question  on 
which  the  progressive  physician  and  the  philan- 
thropic politician,  if  such  rara  avis  exists,  should 
be  a unit. 

9.  (a)  Perverted  conception  and  mal-adminis- 
tration  of  the  law.  {b)  Unjust  dispensation  of 
the  law,  statutory  and  moral.  Illogical  interpre- 
tation of  divine  law.  This  cause  is  of  more  im- 
portance than  is  usually  assigned  to  it.  What 
may  be  termed  the  inequalities  of  Justice  have 
been  responsible  for  fully  as  many  cases  of  con- 
firmed criminality  as  almost  an}’  other  cause 
which  could  be  mentioned. 

Bishop  Robertson  once  said:  “Justice  is  a pair 
of  huge  iron  jaws  which  open  and  close  with  me- 
chanical regularity.  Nearly  every  man  at  some 
time  in  his  life  comes  within  the  legitimate  reach 
of  these  jaws.  Many  escape  just  at  the  nick  of 
time  because  they  do  not  happen  to  be  within 
reach  at  the  time  the  jaws  are  open  and  closing, 
while  others  less  guilty  perhaps,  but  also  less  for- 
tunate, are  caught.  ’ ’ 

4 A movement  is  now  on  foot  to  establish  a reformatory  in 
Chicago 


105 


A very  interesting  story  is  told  in  this  connec- 
tion of  two  school  boys  who  were  stealing  apples 
together.  They  were  detected  and  pursued.  One 
was  caught,  while  the  other  one  escaped.  The 
one  who  was  captured  was  sent  to  jail  and  thrown 
among  criminals  from  whom  he  acquired  a moral 
contagion  which  infected  his  after  life.  After  his 
release  those  acts  which  before  his  incarceration 
were  merely  boyish  pranks,  assumed  a criminal 
character  and  he  became  a confirmed  criminal. 
The  boy  who  escaped  remained  in  school  and 
doubtless  kept  up  his  mischievous  tricks  during 
his  school  days.  He  afterward  studied  law,  be- 
came a lawyer,  and  eventually  was  elected  a j u dge . 
Twenty-five  years  after  the  apple  stealing  episode 
the  judge  sentenced  his  former  comrade  to  death 
for  murder. 

lo.  Alleged  detective  science  or  man-hunting. 
The  manner  in  which  the  ambitious  modern 
would-be  detective  pursues  discharged  criminals 
is  an  apt  illustration  of  “man’s  inhumanity  to 
man.”  How  frequently  it  transpires  that  a crim- 
inal leaves  the  prison  gates  with  the  resolve  to 
lead  an  hone.st  life;  he  secures  a position  but  the 
eye  of  the  law  is  still  upon  him,  and  some  human 
tiger  in  the  guise  of  a detective  speedily  warns 
his  employer  that  he  is  harboring  a jail  bird. 
Discharge  follows,  and  perhaps  another  place  is 
secured  with  the  same  result,  and  so  the  relentless 
pursuit  goes  on  and  on  until  the  jail  bird  finds 
every  avenue  closed  to  him  except  the  road  back 
into  the  jail.  Why  have  we  not  a Hugo  among 
us  to  describe  the  pursuit  and  persecution  of 
our  own  Valjeans?  It  is  unquestionably  true 
that  the  persecution  of  criminals  by  would-be 
Vidocqs  does  much  to  keep  up  the  census  of  our 
jails.  A want  of  faith  in  reformation  on  the  part 
of  those  who  should  hold  out  a helping  hand  to 


io6 


the  criminal,  drives  many  a man  back  to  crime. 

11.  Physical,  moral,  social,  and  matrimonial 
mesalliance.  This  involves  the  question  of  con- 
sanguinity. It  is  questionable  whether  w'e  as 
physicians  will  ever  succeed  in  accomplishing 
much  in  the  correction  of  this  particular  cause. 
The  sanitary  marriage  is  the  dream  of  the  idealist. 
If  we  shoot  at  the  moon  however,  we  may  make 
a pretty  satisfactory  target  though  w^e  fall  far 
short  of  the  mark.  Gross  physical  infirmities 
and  certain  pronounced  mental  defects  may  at 
least  be  taken  into  consideration  in  the  question 
of  matrimony.  Proper  selection  in  marriage 
means  means  both  physical  and  mental  improve- 
ment in  the  race.  The  human  animal  is  certain- 
ly entitled  to  some  of  the  benefits  to  be  derived 
from  the  science  of  breeding.  Authorities  are 
somewhat  divided  upon  the  question  of  consan- 
guinity, yet  there  are  few  who  are  not  willing 
to  admit  the  necessity  of  careful  and  ripe  judg- 
ment in  considering  the  question  of  the  marriage 
of  blood  relations. 

12.  Aberrations  and  per^-ersions  of  a sexual 
character  are  occasionally  the  cause  of  crime, 
more  frequently  perhaps  than  is  generally  appre- 
ciated. Many  cases  of  murder  from  alleged  jeal- 
ousy are  due  to  sexual  insanity.  Rapes  and  var- 
ious crimes  of  a bestial  character  may  be  due  to 
inherent  perversion  or  to  actual  insanity.  There 
are  many  illustrations  of  crime  committed  as  a 
consequence  of  inherent  sexual  perversion. 

13.  The  intermarriage  of  criminals.  As  much 
as  has  been  said  upon  this  question,  it  is  doubtful 
whether  the  correction  of  this  influence  by  the 
State  is  possible.  If  the  privilege  of  matrimony 
be  denied  to  the  criminal  class,  illegitimate  rela- 
tions are  apt  to  be  established  with  an  even  more 
deplorable  result.  Such  people  are  not  apt  to 


107  ■ 


stand  on  ceremony,  and  the  correction  of  this 
cause  is  therefore  more  theoretical  than  practised. 

14.  Corruption  in  politics.  Under  this  head  I 
will  embrace  political  encouragement  of  ruffianism 
and  protection  for  criminals.  A very  sad  case 
recently  occurred  in  Chicago  of  a prominent  law- 
yer who  became  insane  as  a consequence  of  a blow 
upon  the  head  inflicted  by  an  alleged  respectable 
citizen  during  a quarrel  of  a political  character. 
As  a corollary  of  political  corruption  we  have  an 
imperfect  and  corrupt  police  system,  the  keystone 
of  which  is  the  axiom  that  it  takes  a rascal  to 
catch  a rascal.  This  cause  of  criminality  must 
prevail  as  long  as  the  credentials  of  an  alderman 
are  the  qualities  of  a deep,  hard  drinker  and  a 
good  rough-and-tumble  fighter. 

15.  Niggardly  and  misapplied  charity,  with 
consequent  failure  to  relieve  actual  want.  As  is 
well  known,  starvation  and  crime  are  first  cousins. 

16.  The  importation  of  the  criminal  refu.se  of 
the  Old  World,  and  what  is  worse,  individuals 
with  fanatical  social,  political  or  religious  views. 
The  important  question  of  immigration  demands 
more  attention  than  is  usually  accorded  it.  It  is 
really  one  of  the  most  vital  issues  of  the  day.  The 
instance  has  been  known,  and  quite  recently,  that 
nearly  ten  thousand  immigrants  were  landed  in 
one  day  at  Castle  Garden  alone,  to  say  nothing 
of  other  ports  of  entry.  Were  it  established  that 
all  of  these  people  are  respectable  and  producing 
elements  in  American  society,  they  would  certain- 
ly be  a very  valuable  addition  to  our  population. 
There  is  something  striking  however,  in  the  fact 
that,  although  the  foreign- born  citizens  constitute 
but  one- eighth  of  the  total  population  of  the  coun- 
try they  furnish  one- third  of  our  criminals, 
one-third  of  our  paupers,  and  one-third  of  our  in- 
sane. In  short,  the  character  of  our  immigrants 


. io8 


is  so  polluted  by  the  wholesale  exportation  by  the 
Old  World  of  the  insane,  criminal  and  pauper  class, 
that  every  one  thousand  immigrants  furnishes 
twenty  per  cent,  more  of  the  inmates  for  our  jails, 
asylums  and  alms-houses  than  the  same  nnmber 
of  American  born.  This  is  a cause  which  must 
be  grappled  with  by  the  statesman  and  not  by  the 
philanthropist.  Should  politics  become  honest, 
or  approximately  so,  there  is  hope  for  remedying 
this  evil,  but  under  the  present  system  of  political 
quackery  a remedy  for  this  cause  is  like  some  of 
the  others  I have  mentioned,  more  theoretical 
than  practical. 

In  this  array  of  generalities  and  necessarily  im- 
perfect classification  of  causes  of  vice  and  crimi- 
nality, it  is  obviously  impossible  forme  to  entire- 
ly cover  the  field,  but  if  I have  succeeded  in  pre- 
senting in  an  intelligible  manner  ideas  which  will 
serve  as  an  incentive  for  the  studj^  of  the  subject 
on  the  part  of  my  intelligent  readers,  I shall  have 
accomplished  my  object.  As  Dumas  once  said  of 
mendicity:  Criminality  is  ‘‘an  organized  bod}",  a 
kind  of  association  of  those  who  have  not,  against 
those  who  have.”  It  is  high  time  that  the  respect- 
able elements  of  society  should  begin  the  study 
of  the  causes  and  prevention  of  crime  in  a philo- 
sophical manner.  If  this  be  done  and  the  philos- 
opher, preacher,  statesman,  jurist  and  physician 
put  their  shoulders  to  the  wheel  and  work  in 
unison,  the  time  ma}"  come  when  the  criminal 
class  may  not  be  so  pronounced  a curse  in  our 
social  system  as  it  is  to-day. 


THE  RATIONALE  OF  EXTENSION  IN  DISEASES  OF 
THE  SPINAL  CORD,  WITH  METHODS  FOR 
SECURING  THE  SAME. 


It  IS  hardl}^  necessary  to  go  into  details  regarding 
the  history  of  the  modern  method  of  treatment  of  dis- 
eases of  the  spine  by  extension.  It  is  my  purpose  in 
the  present  paper  to  devote  attention  chiefly  to  loco- 
motor ataxia,  this  being  the  disease  for  which  exten- 
tion  of  the  spine  has  of  late  been  most  frequently 
employed.  Not  being  a specialist,  either  in  nervous 
diseases  or  orthopaedics,  my  object  in  the  publication 
of  this  paper  is  merely  to  offer  what  I consider  to  be 
a logical  explanation  of  the  action  of  extension  of  the 
spine  in  the  treatment  of  diseases  of  the  spinal  cord, 
and  to  present  a method  of  extension  which  I am  con- 
vinced is  the  best.  Extension  of  the  spine  as  the 
treatment  for  locomotor  ataxia  was  first  introduced  by 
Motchoukowski,  of  Odessa,  in  1883.  The  method  of 
extension  which  he  adopted  was  by  the  use  of  the  sus- 
pension apparatus  originally  applied  in  Pott's  disease 
of  the  spine  by  Dr.  Joseph  Bryan,  of  Bellevue  Hos- 
pital (now  of  Kentucky),  from  whom  tradition  says  it 
was  pilfered  by  the  more  or  less  celebrated  Sayre,  of 
New  York.  Within  the  past  year  the  renowned 
Charcot,  of  Paris,  has  adopted  this  method  of  sus- 
pension in  locomotor  ataxia.  Many  prominent  Amer- 
ican neurologists  have  experimented  extensively  with 
the  method  and  have  indorsed  it  as  a rational  and 
successful  measure  of  treatment.  Dana,  and  Morton, 
among  the  neurologists,  and  Charles  F.  Stillman,*  the 


* Recently  deceased. 


I lO 


well-known  authority  upon  orthopaedics,  have  written 
quite  extensively  upon  the  subject. 

In  an  excellent  article  upon  the  mechanics  of  exten- 
sion of  the  spine,  Stillman  presents  the  present  status 
of  extension  in  locomotor  ataxia,  summing  up  with 
the  statement  that  “the  precise  effect  of  suspension 
upon  the  spinal  cord  and  nerves  in  this  disease  is  not 
as  yet  determined.”  Motchoukowski  believes  that 
the  improvement  noticed  in  his  cases  is  due  to  “ an 
increased  activity  of  the  circulation  induced  by  sus- 
pension.” He  observed  an  increase  of  arterial  tension 
with  increased  rapidity  of  pulse  and  respiration  dur- 
ing suspension.  He  states  also  that  in  experimenting 
upon  the  cadaver  he  produced  a lengthening  of  the 
spine  between  the  second  cervical  and  fourth  lumbar 
vertebrtE  of  two  and  one-half  centimeters.  The  con- 
sensus of  opinion  has  been  corroborative  of  the  fore- 
going, it  being  generally  believed  that  the  improve- 
ment in  circulation  and  in  the  nutrition  of  the  spinal 
cord  to  which  the  improvement  in  the  symptoms  is 
attributed,  is  due  to  a stretching  of  the  spinal  cord 
proper.  Dr.  Dana*  indorsed  the  method  in  a rather 
lukewarm  fashion  and  states  that  “ it  is  a method  of 
treatment  which  is  inferior  to  others  in  our  posses- 
sion.” Dr.  Morton f says,  “the  subject  is  just  enter- 
ing upon  its  experimental  and  clinical  stage,  but  if 
we  accept  the  facts  thus  far  reported  and  if  the)'  prove 
to  be  accurate  in  a large  number  of  cases  we  shall  be 
compelled  to  admit  that  the  sum  total  of  improvement 
is  far  in  excess  of  that  attainable  by  any  previous 
means.  ” 

This  author  is  seemingly  on  the  fence  as  far  as  the 
explanation  of  the  therapeutical  action  of  extension  of 
the  spine  is  concerned.  He  asks:  “What  are  the 
effects  of  suspension  upon  the  healthy  spinal  cord? 
What  the  cause  of  the  effect  upon  the  diseased  cord  ? 
Is  it  due  to  a diminution  of  the  irritibility  of  the  cord 
by  stretching  it  ? Can  or  cannot  the  cord  be  actually 
elongated?”  Waitzfelder  J says  : “ It  is  hardly  rea 
sonable  to  suppose  that  the  cord  itself  is  stretched, for 
it  floats  so  freel)'  in  the  spinal  canal  that  the  counter- 


^ Medical  Record,  April  13,  1889. 
f Medical  Record,  April  13,  1889. 
t Medical  Record,  April  13,  1889. 


1 1 1 


extension  of  the  weight  of  the  body  is  notsufficient  to 
produce  that  result  without  the  greatest  pain.  It  is 
more  likely  that  the  traction  exerted  on  the  spinal 
nerves  in  some  way  brings  about  a change  in  the  cir- 
culation and  nutrition  of  the  cord,  and  the  ameliora- 
tion of  the  symptoms  is  due  to  a lessening  of  the  vascu- 
lar supply  of  the  cord  and  its  membranes  * The  Journal 
of  the  American  Medical  Associationior  Se-ptemher  7th, 
i88g,  states  that  “the  rationale  of  the  treatment  is  not 
very  evident.  Experiments  have  shown  that  on  the 
cadaver  at  least  the  vertebral  canal  is  sufficiently 
elongated  to  exert  slight  traction  upon  the  spinal  cord 
by  the  nerve  roots,  but  why  this  should  be  beneficial 
is  not  quite  clear.”  Althaus  thinks  that  “ the  im- 
provement is  due  to  a breaking  up  of  adhesions  in 
the  meninges  and  neuroglia. 

I fail  to  see  how  any  of  the  explanations  of  the  me- 
chanical cause  of  improvement  in  the  nutrition  of  the 
cord  which  have  thus  far  been  offered  in  the  consid- 
eration of  the  treatment  of  locomotor  ataxia  by  exten- 
sion, can  be  consistent  with  our  knowledge  of  the 
anatomy  of  the  spinal  column,  the  spinal  canal  and 
its  contents.  I do  not  belidve  that  it  is  possible  by 
stretching  of  the  spinal  column  to  exert  sufficient  trac- 
tion upon  the  loosely  attached  spinal  cord  either  to 
stretch  it,  or  secondarily  to  stretch  the  spinal  nerves. 
It  certainly  appears  to  me  absolutely  impossible  to 
exert  a traction  force  upon  the  cord  through  the  me- 
dium of  the  spinal  nerves.  Indeed,  the  structure  of 
the  spinal  canal  and  its  contents  is  such  apparently 
as  would  defeat  any  attempt  at  direct  traction  upon 
the  cord  or  its  nerves.  The  spinal  cord  does  not 
completely  fill  the  spinal  canal,  its  investing  mem- 
branes being  invested  by  areolar  tissue  and  a rich 
plexus  of  veins  and  capillaries  which  separate  the 
cord  from  the  bony  walls  of  its  canal.  As  compared 
with  the  length  of  the  spinal  canal  the  spinal  cord  is 
relatively  very  short,  extending  only  from  the  fora- 
men magnum  to  the  lower  border  of  the  first  lumbar 
vertebra. 

It  is  unquestionably  true,  as  proven  by  experiments 
upon  the  cadaver,  and  as  I have  observed  in  experi- 


* Italics  mine. 
I Editorial. 


I 12 


ments  upon  the  living  subject,  tnat  the  spinal  column 
can  be  extended.  Now,  if  this  extension  produces 
improvement  in  the  general  circulation  and  in  the  nu- 
trition of  the  spinal  cord,  and  if,  moreover  (as  I 
believe),  it  is  not  practicable  to  exert  sufficient  trac- 
tion to  stretch  the  spinal  cord  or  its  nerves  within  the 
limits  of  safety,  there  seems  to  be  some  other  expla- 
nation of  the  action  of  extension.  I believe  that  ex- 
tension does  produce  both  local  and  general  improve- 
ment in  nutrition,  but  I do  not  believe  that  this  result 
is  attained  through  traction  upon  the  cord  or  the 
spinal  nerves.  The  spinal  column  is  composed  of  a 
number  of  firm,  bony  segments  united  together  by 
elastic  and  inelastic  structures.  The  elastic  bonds  of 
union  between  the  vertebrae  (chiefly  the  ligarnenta 
subflava)  are  the  media  through  which  extension  of 
the  spine  is  possible  within  certain  limits.  The  ine- 
lastic structures,  although  perhaps  extensible  within 
certain  limits,  are  the  principal  agents  in  limiting  the 
range  of  elasticity  of  the  ligarnenta  subflava.  In  a 
general  way  it  may  be  said  that  the  vertebrae  consti- 
tute the  rigid  segments  of  the  spine,  while  the  inter- 
vertebral tissues  and  ligaments  constitute  the  exten- 
sible and  more  or  less  elastic  segments  of  the  spine. 
These  segments  constitute  the  walls  of  a canal  which 
in  its  entirety  is  quite  capacious.  Admitting  that  it 
is  perfectly  practicable  to  lengthen  the  spinal  column, 
it  is  a self-evident  fact  that  the  cavity  in  which  the 
spinal  cord  and  its  investments  rest,  is  increased  in 
its  capacity  to  a degree  proportionate  to  the  length- 
ening of  the  spinal  column.  The  increase  of  capacity" 
would  be  represented  by  a cylinder  of  a length  cor- 
responding to  the  increase  in  the  length  of  the  spinal 
cord  when  fully  extended,  with  a mean  diameter  cor- 
responding to  that  of  the  spinal  canal.  This  will  be 
admitted  by  all  who  believe  that  lengthening  of  the 
spine  by  extension  is  practicable.  This  fact  having 
been  admitted,  its  corollary  is  at  once  obvious.  There 
is  formed  a vacuum  of  greater  or  less  capacity  within 
the  spinal  canal,  the  result  of  which  is  an  aspirating 
or  suction  force  along  its  entire  length.  The  simplest 
of  ph5^sical  principles  explains  the  rest.  There  is  an 
active  determination  of  blood  to  the  part,  with  a con- 
sequent stimulation  of  the  functions  of  the  cord,  and  an 
improvement  in  its  nutrition  which  lasts  for  some 


”3 


time  after  the  tension  upon  the  spinal  column  has 
been  removed.  An  incidental  element  in  the  im- 
provement of  nutrition  is  a lessening  of  resistance  to 
the  venous  flow.  The  effect  of  an  increased  vis  a 
tergo  and  a diminished  vis  a fronte  is  at  once  apparent. 

The  improvem.ent  in  the  general  circulation  inci- 
dental to  extension,  if  properly  performed,  is  very  evi- 
dent even  to  a casual  observer.  The  extremities, 
which  in  locomotor  ataxia  are  cold  and  show  evi- 
dences of  faulty  circulation,  grow  warm  and  redden 
during  the  continuance  of  suspension.  This  improve- 
ment in  circulation  will  be  observed  to  remain  for  a 
greater  or  less  length  of  time  after  suspension  is 
stopped.  The  pulse  will  be  found,  during  extension 
of  the  spine,  at  least  by  the  method  which  I am  about 
to  indorse,  to  grow  more  frequent  and  fuller;  respira- 
tion is  also  increased. 

The  so-called  Sayre  method,  as  advocated  by 
Motchoukowski  and  Charcot,  is  in  my  opinion  a very 
faulty  one,  and  is  by  no  means  free  from  the  element 
of  danger.  Some  four  or  five  cases,  if  not  more,  have 
been  reported  in  which  death  has  occurred  as  a direct 
consequence  of  shock  of  asphyxia  induced  by  the  sus- 
pension method.  The  method  is  certainly  painful 
and  the  risk,  considering  the  number  of  deaths  that 
have  occurred  from  it  during  its  short  existence,  is 
considerable.  The  traction  upon  the  spine  is  exerted 
in  an  indirect  manner.  It  is  produced  solely  by  lon- 
gitudinal traction,  no  attempt  being  made  to  take  ad- 
vantage of  certain  mechanical  principles  which  can 
be  applied  to  the  spine.  The  method  certainly  entails 
hard  work  upon  the  patient,  the  first  principle  of  treat- 
ment of  locomotor  ataxia,  viz.:  rest,  beingdisregarded. 
The  disproportionate  strain  upon  the  cervical  portion 
of  the  spinal  column  is  considerable.  There  seems 
to  be  a tendency  to  attempt  stretching  and  straighten- 
ing of  the  spinal  column  by  traction  upon  this  rela- 
tively short  and  fragile  region  of  the  spine.  Not  only 
is  this  region  of  the  spine  rather  delicate,  but  traction 
upon  it  involves  tension  upon  certain  very  important 
nervous,  vascular  and  muscular  structures  of  the  neck. 

In  addition  to  the  increased  capacity  of  the  spinal 
canal,  incidental  to  extension  of  the  spinal  column, 
there  is  an  increase  of  capacity  due  to  a thinning  of 
the  various  intervertebral  structures.  The  straighten- 


1T4 

ing  out,  the  stretching  and  unfolding  of  the  variousllga- 
ments  of  the  spinal  column  enhances  the  aspirating 
effect  upon  the  spinal  column  as  a whole  as  well  as 
upon  the  spinal  canal. 

That  stretching  of  the  cord  is  not  the  essence  of  the 
beneficial  result  is,  I think,  conclusively  shown  by  the 
circulatory  effect  of  extension.  Stretching  of  a nerve 
does  not  heighten  its  functions, co7itra,  it  inhibits 
them  temporarily.  The  results  of  stretching  the 
sciatic  show  this. 

In  considering  the  mechanics  of  the  treatment  of  lo- 
comotor ataxia  by  extension  of  the  spine,  it  is  neces- 
sar}^  to  consider  the  fact  that,  according  to  my  theory, 
it  is  not  necessary  to  bring  to  bear  upon  the  spinal 
column  extreme  and  painful  tension,  it  being  only 
necessary  to  bring  about  such  a degree  of  lengthening 
of  the  spinal  column  as  will  secure  the  aspirating  ef- 
fect which  I have  described.  Anotner  point  which 
should  be  taken  into  consideration  (and  this  is  es- 
pecially pertinent  in  extreme  cases),  is  the  position 
which  the  patient  involuntarih'  assumes.  There  is  a 
tendency  not  only  to  flexion  of  the  spine  but  of  the 
limbs.  Thus  the  spine  is  curved  backward,  so  that 
the  patient  has  a decidedly  round-shouldered  appear- 
ance ; the  forearm  tends  to  become  slightly  flexed 
upon  the  arm  ; the  hands  tends  to  droop,  the  fingers 
being  held  in  a semi-flexed  position;  the  thighs  some- 
what flexed  upon  the  abdomen ; the  legs  upon  the 
thighs — there  is  a decided  curve  of  the  feet.  I am 
now  describing  typical  cases  which  in  man}-  instances 
are  bedridden.  This  general  tendency  to  flexion, 
however,  may  be  observed  in  cases  of  moderate 
severity. 

This  flexion  of  the  spine  is  probably  nature’s 
method  of  supporting  the  spine  in  this  disease.  It  is 
analogous  to  the  hyper- extension  of  the  spinal  column 
observed  in  that  form  of  Pott’s  disease  in  which  the 
bodies  of  the  vertebras  are  chiefly  affected.  This  con- 
dition of  flexion  of  the  spine  must  be  corrected  by 
our  measures  of  extension,  else  the  treatment  will 
hardly  ]irove  efficacious.  Obviously  it  would  be  very 
difficult  to  extend  this  curved  column  without  re- 
ducing in  a great  measure  its  abnormal,  and  for  that 
matter,  normal  curves.  To  attempt  to  straighten  the 
spinal  column  by  a pulling  process  alone  is  not  com- 


patible  with  the  best  results  nor  with  the  intelligent 
application  of  simple  mechanical  principles. 

The  method  of  extension  of  the  spine  introduced 
by  Dr.  Charles  F.  Stillman,  of  Chicago,  not  only 
permits  of  the  application  of  the  proper  mechanical 
principles  to  the  process  of  extension  of  the  spinal 
column,  but  also  permits  of  the  application  of  the 
treatment  while  patient  is  practically  at  rest.  It  is  a 
perfectly  safe  method  and  is  so  much  more  comfort- 
able and  efficacious  than  the  so-called  Sayre  method 
that,  a patient  having  once  tried  the  improved  process 
will  scarcely  submit  to  the  pain  and  inconvenience 
incidental  to  suspension. 

In  explaining  the  advantages  of  his  method.  Dr. 
Stillman  says;  “The  spinal  canal  is  posterior  to  the 
main  portion,  i.  e.,  the  bodies  and  the  intervertebral 
cartilages  of  the  vertebral  column,  and  this  is  an  an- 
atomical feature  to  be  emphasized,  because  on  account 
of  this  arrangement  it  is  plain  that  a given  amount  of 
traction  exerted  on  the  column  in  an  anterior  curved 
position  (this  anterior  curving  or  flexion  being  the 
most  extensive  of  any  of  its  movements  and  freely 
permitted  in  the  cervical  and  lumbar  regions),  must 
result  in  greater  elongation  of  the  cord  itself  situated 
behind  the  vertebral  bodies,  than  an  equal  amount  of 
traction  exerted  with  the  spinal  column  in  any  other 
position. 

As  I have  observed  under  the  manipulations  of  Dr. 
Stillman,  the  spinous  processes  will  be  found  to  sepa- 
rate quite  appreciably.  The  point  to  which  I take 
exception  in  Dr.  Stillman’s  description  is  the  assertion 
that  this  method  results  in  greater  elongation  of  the 
cord.  This  I do  not  believe,  for,  as  I have  already 
claimed,  I think  it  is  the  aspirating  effect  which  is 
secured  upon  the  spinal  canal  and  not  an  elongation 
of  the  cord  that  produces  the  beneficial  results.  I am 
inclined  to  accept  the  assertion  that  traction  upon  the 
board  with  the  patient  in  the  prone  position  secures 
the  greatest  possible  increase  in  the  capacity  of  the 
spinal  canal.  A bending  of  the  spine  anteriorly  will 
force  the  anterior  edges  of  the  vertebral  bodies  to- 
gether to  such  a degree  as  to  neutralize  perhaps  to  a 
certain  extent  the  apparent  elongation  of  the  spinal 
column  as  a whole,  as  evidenced  by  the  separation  of 
the  spinous  processes,  but  such  a tipping  together  of 


ii6 


the  vertebral  bodies  will  necessarily  result  in  a rela- 
tively wide  separation  of  that  portion  of  the  vertebrae 
enclosing  the  spinal  canal.  While  this  separation 
therefore  is  not  a perfectly  reliable  criterion  of  the  de- 
gree of  extension  of  the  spinal  column  it  increases  the 
capacity  of  the  canal. 

Stillman  has  recommended  not  only  gymnastic 
treatment  while  the  patient  is  subjected  to  traction 
upon  his  curved  board,  but  also  the  application  of 
electricity  and  massage. 

Obviously  these  methods  of  treatment  are  most 
efficacious  at  the  time  when  the  patient’s  vitality  has 
been  heightened  under  the  influence  of  proper  trac- 
tion ; or,  according  to  my  views,  under  aspiration  of 
the  spinal  canal  by  elongation  of  the  spinal  column. 

In  conclusion,  I will  present,  and  at  the  same  time, 
indorse  the  r^sum^  given  by  Dr.  Stillman  in  a recent 
paper  read  before  the  Chicago  Medical  Society.*  In 
addition  to  constitutional  treatment  in  locomotor 
ataxia  there  should  be  employed  . 

1.  Both  the  erect  and  recumbent  curved  traction 
frames  as  being  superior  both  in  principle  and  prac- 
tice to  the  so-called  Sayre  suspension  apparatus,  em- 
ployed by  Motchoukowski  and  Charcot. 

2.  Traction  while  the  spine  is  curved  anteriorly  to 
produce  the  greatest  possible  degree  of  elongation  of 
the  cord  and  spinal  nerves  (?)  consistent  with  a 
requisite  amount  of  rest,  comfort,  and  freedom  from 
danger. 

3.  Traction  while  the  spine  is  curved  posteriorh’ to 
increase  the  vital  power. 

4.  Appropriate  gymnastic  exercises  during  the 
curved  traction  to  restore  impaired  muscular  function 
and  to  improve  general  nutrition. 

5.  Appropriate  forms  of  electricity  and  massage 
while  traction  and  rest  are  being  practiced. 

I would  suggest,  as  an  additional  factor  in  the 
treatment,  that  such  exercises  be  selected  as  will  in- 
crease the  chest  capacity,  as  we  thus  take  advantage 
of  the  improvement  in  circulation  and  haematosis 
incidental  to  exaggerated  respiration.  The  pullej'S 
introduced  by  Dr.  Stillman  are  efficacious  in  this 
procedure,  providing  the  proper  means  are  secured. 


* Trans.  Chicago  Med.  Soc,  Dec.  2d,  1889 


TR0PH0-MEUR05I5  AS  A FACTOR  IN 
THE  PHENOMENA  OF 
SYPHILIS. 


In  studying  some  of  the  late  or  sequelar  lesions  of 
syphilis,  particularly  those  involving  changes  in  the 
oseous  structures  of  the  head  and  face,  I have  been 
forcibly  impressed  by  certain  characters  of  the  lesions 
which  seem  to  depend  upon  a more  occult  series  of 
pathological  changes  than  those  to  which  they  are 
usually  accredited.  Some  of  these  characteristics 
also  pertain  to  many  of  the  lesions  of  the  active  or 
secondary  period  of  syphilis. 

The  relation  of  certain  syphilitic  phenomena  to 
organic  or  functional  disturbances  of  the  nervous  sys- 
tem— and  particularly  the  sympathetic  system — is 
certainly  manifested  here  and  there  along  the  whole 
line  of  morbid  phenomena  developed  in  the  course  of 
the  disease.  The  syphilitic  fever,  so-called,  while  an 
inconstant  phenomenon,  is  present  in  a sufficient  num- 
ber of  cases  of  the  disease  to  practically  settle  the 
question  of  the  relation  of  cause  and  effect.  The 
symptoms  which  collectively  we  designate  syphilitic 
fever,  are,  in  common  with  some  other  febrile  consti- 
tutional disturbances,  undoubtedly  dependent  upon 
the  action  of  a special  poison  upon  the  sympathetic 
nervous  system.  It  is  logical  to  infer  from  Vv^hat  we 
know  of  the  phj^siology  of  the  sympathetic  system, 
and  particularly  of  those  functions  of  the  sympathetic 
which  we  term  trophic,  that  the  majority  of  fevers — if 
not  all— are  directly  dependent  upon  the  action  of  the 
specific  poison  upon  the  sympathetic  ganglia,  which 
action  is  manifested  by  disturbed  metabolism  and  the 
resulting  phenomena  of  fever.  So  in  the  case  of 
syphilis  the  poison  may  produce  so  profound  an 
impression  upon  the  sympathetic  ganglia  that  the 


ii8 


trophic  function  of  this  portion  of  the  nervous  system 
is  disturbed,  with  an  attendant  perversion  of  tissue 
metabolism,  a resultant  excessive  production  of 
animal  heat  and  the  accumulation  in  the  system  of  the 
toxic  products  of  perverted  physio-chemical  change. 
The  fact  that  the  so-called  syphilitic  fever  is  not  a 
constant  phenomenon,  but  affects  only  a certain  por- 
tion of  individuals  attacked  by  syphilis  is  explicable 
upon  the  ground  of  idiosyncras}^ 

The  argument  that  the  syphilitic  fever  is  the  result 
of  an  impression  produced  by  the  syphilitic  poison 
upon  the  sympathetie  nervous  system  does  not  neces- 
sarily imply — nor  do  I intend  it  to  do  so — that  the 
syphilitic  fever  is  a part  of  the  natural  course  of  the 
disease.  On  the  contrary,  I believe  that  it  is  acci- 
dental and  the  result  of  idiosyncrasy.  We  know  that 
different  individuals  are  variously  affected  by  the  con- 
stitutional impression  of  organic  poisons.  Certain 
individuals  are  affected  by  urticaria  or  erythema  upon 
the  ingestion  of  shell-fish,  this  result  being  particularly 
apt  to  follow  when  the  particular  article  of  food  is  not 
perfectly  fresh  or  was  not  in  an  absolutely  healthy 
condition  when  taken  for  food.  Some  persons  are 
seriously  affected  by  the  ingestion  of  certain  vegeta- 
bles— particularly  if  partial  decomposition  has  oc- 
curred. Canned  vegetables,  and  especially  tomatoes, 
are  especially  liable  to  impeachment  upon  this  ground. 
If  it  is  fair  to  infer  that  by  virtue  of  idiosyncras\’  the 
nervous  system  of  certain  individuals  may  be  mor- 
bidly impressed  by  certain  food  substances  which  are 
innocuous  to  the  majority  of  individuals,  it  is  certainly 
fair  to  assume  that  in  the  case  of  so  powerful  an 
organic  poison  as  that  of  syphilis,  with  which  a large 
number  of  individuals  are  inevitabl}'  inoculated,  cer- 
tain special  and  exceptional  phenomena  might  be 
produced  in  some  persons. 

Attendant  upon  or  following  the  syphilitic  fever,  or 
occurring  independent!}^  of  it,  we  have  a characteris- 
tic manifestation  of  syphilis,  which  in  cases  unmodi- 
fied by  treatment  is  probabl}^  always  present  in  greater 
or  less  degree.  I refer  to  the  syphilitic  roseola. 
This  eruption  has  been  shown  to  be  unlike  the  other 
phenomena  of  syphilis  in  that  it  is  dependent,  not 
upon  a localized  collection  of  proliferating  syphilized 
cells,  but  upon  vaso-motor  disturbances,  the  essential 


iig 

objective  element  of  which  consists  in  dilatation  of 
the  capillaries  in  localized  areas  of  the  skin.  This,  as 
far  as  we  are  able  to  positively  determine,  is  depend- 
ent upon  the  impression  of  the  syphilitic  poison — 
virus,  bacillus,  degraded  cell,  or  whatever  term  may 
be  selected  to  designate  it — upon  the  central  sympa- 
thetic system.  This  impression  is  essentially  the 
same  as  that  produced  by  certain  vegetable  poisons. 
It  is  not,  however,  dependent  upon  idiosyncrasy,  al- 
though it  may  be  modified  by  it;  thus  we  find  in  some 
individuals  a very  marked  roseola,  in  which  the 
lesions  are  disseminated  over  a large  area  of  the  integ- 
umentary surface  and  are  very  prominent  and  well- 
defined;  whereas  in  others  we  may  find  upon  close 
inspection  perhaps  but  a single  lesion.  The  grada- 
tions between  the  two  extremes  are  very  various. 
Idiosyncrasy  might  be  quite  plausibly  advanced  as 
the  explanation  of  this  wide  variation. 

The  action  of  certain  drugs  given  for  medicinal 
purposes  is  a further  illustration  of  the  results  of 
various  poisons  upon  the  sympathetic  nervous  system 
as  manifested  by  the  appearance  of  morbid  cutaneous 
phenomena.  Belladonna,  quinine,  opium,  copaiba, 
chloral,  salicylic  acid  and  numerous  other  drugs  have 
been  found  to  produce,  in  exceptional  cases,  an 
efflorescence  upon  the  skin.  The  rarity  of  such 
phenomena,  in  conjunction  with  other  proofs  of 
idiosyncrasy  and  the  known  properties  of  these  vari- 
ous drugs  as  far  as  their  action  upon  the  skin  is  con- 
cerned, are  positive  evidences  of  their  neurotic  char- 
acter. 

The  lesions  of  syphilis  which  succeed  the  roseola 
have  been  so  positively  demonstrated  to  be  dependent 
upon  a localized  deposit  and  proliferation  of  syphi- 
lized  cell  mat  .rial  that  it  would  appear  to  be  impossi- 
ble to  apply  the  neurotic  theory  to  them.  It  is  only 
necessary,  however,  it  appears  to  me,  to  direct  atten- 
tion to  the  marked  symmetry  which  characterizes  the 
peripheral  phenomena  of  syphilis  to  at  once  suggest 
the  probability  of  a central  nervous  element  in  the 
production  of  the  various  lesions.  It  is,  to  be  sure, 
admitted  that  a symmetrical  development  of  eruptive 
lesions  occurs  in  some  other  affections.  It  will  be 
found,  however,  that  a nervous  element  is  either  posi- 
tively demonstrable,  or  the  skin  lesions  are  so  abun- 


120 


dant  and  general  that  it  would  be  impossible  that  they 
should  be  otherwise  than  symmetrical. 

As  a most  positive  proof  of  the  relation  of  eruptions 
of  the  skin  to  nervous  disturbance  of  a presumably 
trophic  character,  I have  but  to  allude  to  herpes 
zoster.  In  this  disease  we  find  an  accurate  delinea- 
tion of  the  course  of  the  affected  nerve  by  the  erup- 
tion, and  a very  manifest  local  disturbance  of  nutrition 
of  the  affected  tissues.  Generally  some  portion  of 
but  one  side  of  the  body  is  affected  by  this  disease. 
It  is  sometimes  bilateral  and  consequently  of  a more 
serious  character  than  usual.  Some  of  the  later 
lesions  of  syphilis  are  unilateral,  and  as  will  be  shown 
by  a case  shortly  to  be  related,  almost  as  plainly 
referable  to  the  distribution  of  a particular  nerve  as  is 
the  case  with  herpes  zoster.* 

Recurrent  herpes  zoster  is  especially  pertinent  to 
the  question  of  tropho-neurosis.  This  disease  is 
usually  followed  by  cicatrices.  The  first  symptom  is 
a burning  sensation  followed  by  severe  neuralgic 
pains.  Injury  is  often  the  exciting  cause  and  it  is 
frequently  bilateral.  I have  elsewhere  claimed  that 
herpes  progenitalis  is  often  the  result  of  syphilis — 
being  moreover  a pure  neurosis,  due  ist.  to  syphilis, 
2d.  to  worry,  3d.  to  over  active  therapeusis.f  These 
causes  bring  about  disturbed  innervation  and  nutritive 
disorder. 

Professor  Otis,  following  Besiadecki  and  others, 
has  shown  that  the  predilection  of  syphilitic  material 
for  the  papillae  of  the  skin,  is  due  to  the  fact  that  it  is 
at  this  point  that  the  arterial,  venous  and  intervening 
lymphatic  capillaries  come  into  the  most  intimate 
contact;  in  other  ivords,  that  it  is  in  the ''papillae  of 
the  skin  that  the  narrowest  points  in  the  circulatory 
and  lymphatic  flow  are  to  be  found.  The  affinit}'  of 
the  syphilitic  process  for  Umiphatic  structures  ex- 
plains the  rest,  and  we  have  at  various  points  in  the 
superfices  of  the  body  a localized  heaping  up  of  the 
so-called  syphilized  cells.  We  have,  however,  in  the 
roseola,  localized  and  circumscribed  phenomena. 


* Duplay,  Raymond  and  Leloir  report  cases  of  nervous  syphi- 
lis preceded  and  heralded  by  herpes. 

1 Paper  read  before  North  Texas  Med.  Soc.,  Feb.  8,  1890. 
Phila.  Med.  News. 


I2I 


which  are  not  satisfactorily  explicable  upon  anatomical 
grounds.  Why  does  not  the  roseola  appear  in  one 
continuous  blush  over  the  entire  surface  of  the  body  ? 
Is  it  not  because  the  impression  of  the  syphilitic  poi- 
son upon  the  system  is  manifested  through  a vaso- 
motor disturbance  of  the  function  of  the  sympathetic 
ganglia  at  certain  terminals  in  the  skin  ? Dr.  Otis 
accepts  the  neurotic  origin  of  the  roseola,  and  it  is  a 
matter  of  surprise  that  he  should  seek  for  a local  an- 
atomical explanation  of  the  development  of,  for  ex- 
ample, the  syphilitic  papule.  In  view  of  the  logical 
explanation  of  the  roseola,  would  it  not  be  fair  to  in- 
fer that  a similar  condition  of  affairs  prevails  in  the 
case  of  the  other  eruptions  ? — i.  e.,  that  as  a conse- 
quence of  an  impression  made  by  the  syphilitic  poison 
upon  the  sympathetic  ganglia,  their  trophic  functions 
are  disturbed  with  a consequent  disturbance  of  nutri- 
tion and  perverted  tissue  building  at  certain  points 
upon  the  periphery  or  superfices  of  the  body  ? I do 
not  know  whether  this  explanation  of  the  secondary 
eruptions  of  syphilis  has  ever  been  advanced,  but  it 
has  for  some  time  appeared  to  me  to  be  the  most 
logical  explanation  of  the  phenomena  of  syphilis.  It 
is  particular!}^  satisfactor}?  from  the  fact  that  it  covers 
not  only  the  roseola  and  papule,  but  every  other 
lesion  which  may  occur  throughout  the  entire  course 
of  syphilis. 

There  is  perhaps  no  morbid  phenomenon  character- 
istic of  active  syphilis,  which  is  more  difficult  of  ex- 
planation on  purely  mechanical  grounds,  than  the 
alopecia  which  occurs  during  the  secondary  period. 
Very  few  cases,  if  any,  which  are  unmodified  by  treat- 
ment, escape  this  disagreeable  symptom  of  the  dis- 
ease. Indeed,  under  the  most  careful  and  scientific 
treatment,  a greater  or  less  degree  of  alopecia  is  fre- 
quently observed.  The  shedding  of  the  hair  is  limited 
chiefly  to  the  scalp.  The  e}'ebrows  are  affected,  but 
the  beard  is  little  if  at  all  .involved,  as  a rule.  Other 
hairy  parts  of  the  body  are  not  generally  involved, 
even  though  there  ma}"  be  quite  a general  eruption 
over  the  surface  of  the  body.  Should  destructive 
lesions  occur  in  an}'^  situation  supplied  by  hair,  a tem- 
porary or  even  permanent  shedding  will  be  likely  to 
result.  The  manner  in  which  the  hair  is  shed  from 
the  scalp,  is  most  striking  and  characteristic  in  most 


122 


cases;  instead  of  there  being  a general  shedding,  the 
process  seems  to  affect  the  scalp  in  spots,  as  a conse- 
quence of  which,  the  head  assumes  an  embarrassing 
piebald  appearance,  which  he  who  runs  may  read. 
Otis  and  others  attribute  this  alopecia  to  an  accumu- 
lation of  syphilized  germinal  material  in  and  about 
the  hair  follicles,  this  deposit  producing  mechanical 
impairment  of  nutrition  of  th-e  hair,  as  a consequence 
of  which  it  is  cast  off. 

Strange  to  say,  however,  if  this  theory  be  correct, 
lesions  of  the  scalp  of  sufficient  prominence  to  attract 
attention  are  quite  rarely  associated  with  alopecia.  A 
few  small  papules,  pustules  and  crusts  are  occasion- 
ally found,  but  hardly  ever  in  sufficient  amount  to  ac- 
count for  the  extensive  falling  of  the  hair.  It  will  be 
found,  to  be  sure,  that  at  the  site  of  such  lesions  the 
hair  invariably  falls  out.  Now  it  seems  to  me,  that 
if  the  syphilitic  material  had  such  an  affinit}'  for  the 
scalp  as  would  be  indicated  by  the  theory  of  localized 
cell  deposit,  the  cutaneous  lesions  of  this  portion  of 
the  integumentary  surface  would  be  especiall}^  pro- 
nounced. It  is  hardly  probable  that  in  the  presence 
of  such  an  affinitj'  for  the  hair  follicles,  a deposit  of 
syphilitic  material  would  accumulate  to  such  an  ex- 
tent as  would  be  sufficient  to  deprive  the  hair  follicle 
of  nutrition  and  yet  fall  short  of  a sufficient  amount 
to  be  perceptible  externalhc  There  may  be,  it  is 
true,  more  or  less  accumulation  of  germinal  material 
in  the  hair  follicles,  but  there  jmt  remains  the  neces- 
sity for  an  explanation  of  its  deposition  in  this  loca- 
tion. 

From  these  considerations  I have  been  led  to  be- 
lieve that  the  alopecia  of  s}'philis  is  precisel}'  similar 
to  that  which  occurs  in  other  diseases  as  a conse- 
quence of  local  malnutrition  incidental  to  disturbed 
nervous  supply  and  general  malnutrition.  In  certain 
fevers,  for  example,  shedding  of  the  hair  is  quite  com- 
mon during  convalescence — perhaps  well  along  in  the 
period  of  convalesence.  This  is  due  to  a general  per- 
version of  nutrition  which  must  necessaril)'  affect  an 
epidermal  structure  of  a low  grade  of  vitalit}’,  such  as 
the  hair.  This  perversion  of  nutrition  is  in  m}’  opin- 
ion due  to  a greater  or  less  extent  to  disturbance  of 
the  functions  of  the  S5mipathetic  nervous  s^'stem — in 
other  words,  to  tropho-neurosis.  Various  morbid  dis- 


123 


turbances  of  the  nervous  system  are  known  to  effect 
the  vitality  of  the  hair.  Thus  fright  has  been  known 
to  induce  a blanching  of  the  hair,  unquestionably  de- 
pendent upon  perversion  of  the  functions  of  the  sym- 
pathetic ganglia.  Neuralgic  affections  of  the  head 
are  well  known  to  produce  both  blanching  and  falling 
of  the  hair,  perhaps  limited  to  the  distribution  of  the 
terminal  filaments  of  a single  nerve.  As  a further 
illustration  of  the  relation  of  malnutrition,  probably 
dependent  upon  perversion  of  the  functions  of  the 
sympathetic  nervous  system  to  falling  of  the  hair,  may 
be  mentioned  the  alopecia  resulting  from  the  exces- 
sive use  of  arsenic  internally. 

The  relative  immunity  which  the  beard  of  the  male 
enjoys  as  compared  with  the  hair  of  the  scalp,  is  prob- 
ably dependent  upon  the  greater  intrinsic  strength  of 
the  hair  growth  and  the  higher  vascularity  of  the  tis- 
sues of  the  face. 

Traumatism  may  cause  alopecia  areata  by  an  im- 
pression upon  the  sympathetic  system.  Leloir, 
Dumesnil  and  others  have  recorded  cases  of  this  kind. 
Joseph’s  experiments  are  quite  significant  in  this  con- 
nection. This  experimenter  divided  the  spinal  gang- 
lion of  the  second  cervical  nerve  in  cats  and  thereby 
produced  baldness. 

It  would  appear  that  syphilitic  infection  not  only 
has  a peculiar  affinity  for  the  sympathetic  nervous 
system,  but  that  this  affinity  is  particularly  marked  in 
the  case  of  the  upper  or  cervical  portion  of  the  sym- 
pathetic. The  proportion  of  lesions  about  the  head, 
face  and  mouth,  is  relativel}^  much  larger,  even  under 
the  best  of  treatment,  than  in  other  portions  of  the 
body.  The  parts  supplied  by  the  fifth  cranial  nerve 
appear  to  be  particularly  susceptible.  Very  many  of 
the  cases  with  which  I meet  in  private  practice  es- 
cape, under  appropriate  treatment,  general  cutaneous 
eruptions.  Few,  indeed,  no  matter  how  thoroughly 
they  may  be  treated,  are  not  affected  at  one  time  or 
another  with  lesions  of  the  lips,  inner  surface  of  the 
cheeks,  tongue,  throat  and  scalp.  I find  that  a certain 
degree  of  falling  of  the  hair,  sore  throat  and  mucous 
patches  are  to  be  anticipated  in  spite  of  the  most 
careful  treatment  in  the  larger  proportion  of  cases. 

T have  had  in  my  experience  very  few  cases  in 
which  with  conscientious  attention  to  treatment  the 


124 


patients  have  been  annoyed  by  cutaneous  eruptions, 
bone  lesions,  etc.,  but  I have  had  a number  in  which 
oral  and  pharyngeal  lesions  proved  a source  of  great 
annoyance.  Even  in  the  late  and  sequelar  syphilides 
this  same  predilection  for  the  structures  of  the  face 
and  throat  is  manifest.  Cases  are  frequently  met  with 
in  which  the  initiatory  and  active  periods  of  the  dis- 
ease have  been  passed  through  without  serious 
trouble,  when  suddenly  and  without  warning,  serious 
destruction  of  the  nasal,  palatal  and  maxillary  bones 
has  developed.  Many  cases  of  serious  destructive 
ulceration  of  the  pharynx  are  met  with  as  remote 
manifestations  of  syphilis  in  cases  in  which  anno}'- 
ance  has  been  escaped  during  the-  earlier  periods  of 
the  disease. 

The  affinity  of  the  syphilitic  process  for  the  iris 
may  possibly  be  explicable  from  the  important  func- 
tion of  those  filaments  of  the  S5?mpathetic  s}’stem  sup- 
plied to  this  part.  In  other  words,  the  local  accumu- 
lation of  cells  in  the  iris  may  be  incidental  to  disturb- 
ances of  nutrition  dependent  upon  the  impression  of 
the  syphilitic  poison  upon  the  central  s}'mpathetic 
system. 

Even  in  congenital  syphilis  we  can  see  evidences  of 
tropho-neurotic  disturbance.  The  peculiar  affinity 
of  the  syphilitic  process  for  the  epiph}'so-diaphysial 
junction  of  the  long  bones  is  strikingly  suggestive.  It 
is  here  that  the  processes  of  growth  and  nutrition  are 
most  active  and  tissue-building  the  most  rapid.  It  is 
consequently  at  this  point  that  disturbance  of  the 
trophic  function  of  the  sympathetic  which  presides 
over  the  pli3^siological  processes  of  nutrition  and 
growth  would  be  most  likely  to  be  manifested  b}" 
pathological  cha:.ge.  A perversion  of  the  function  of 
the  S3'mpathetic  would  result  in  imperfect  differentia- 
tion of  the  cells  of  the  part,  and  as  the  rapidit3^  of 
proliferation  of  cells  is  in  inverse  proportion  to  their 
degree  of  differentiation  a heaping  up  of  the  young 
material  is  to  be  expected.  Associated  with  this 
imperfect  differentiation  of  cells,  we  have  a tendency 
to  degeneration,  for  it  may  be  formulated  that  the 
tendency  to  degeneration  is  also  in  inverse  ratio  to  the 
degree  of  differentiation.  This  imperfect  differentia- 
tion with  a consequent  tendenc3^  to  degeneration  of 
young  germinal  material  is  the  characteristic  feature 


125 


of  all  the  lesions  of  syphilis,  no  matter  in  what  stage  of 
the  disease  they  may  develop. 

The  physiological  effects  of  the  remedies  upon 
which  we  depend  for  the  cure  of  syphilis  are  evidences 
of  the  neurotic  character  of  syphilitic  phenomena.  It 
is  shown  that  mercury  and  iodide  of  potassium, 
although  very  efficacious  in  syphilis,  are  in  no  sense 
directly  curative,  their  beneficial  effects  being  depend- 
ent upon  their  power  of  inducing  fatty  degeneration 
and  elimination  of  the  products  of  the  syphilitic  pro- 
cess rather  than  upon  any  special  controlling  or  anti- 
dotal effect  upon  the  poison  per  se,  whether  this 
poison  be  a virus,  germ  or  cell.  In  reviewing  the 
opinions  of  our  best  S3^philographers  regarding  the 
treatment  and  prognosis  of  syphilis,  one  is  impressed 
with  the  idea  that  syphilis  is  a disease  which  runs  a 
natural  course  in  spite  of  treatment,  the  physician 
being  incapable  of  doing  more  with  his  remedies  than 
to  remove  the  effects  of  the  disease  as  fast  as  they 
appear,  thus  preventing  as  far  as  possible  permanent 
damage  to  the  affected  tissues.  As  far  as  aborting  the 
natural  course  of  the  disease  is  concerned,  he  is  abso- 
lutely helpless,  and  apparently  his  success  in  the 
treatment  of  the  disease  is  inversely  to  the  vigor  of 
his  attempts  to  antidote  or  stamp  it  out. 

If  the  neurotic  theory  of  the  essential  condition  in 
syphilis  be  correct,  we  have,  in  our  efforts  to  discover 
a specific  remedy  for  syphilis,  been  necessarily  led 
away  from  those  lines  of  research  which  would  lead  to 
a correction  of  the  principal  element  in  the  production 
of  the  syphilitic  phenomena.  The  severity  of  the  re- 
sults of  syphilis  would  appear  to  depend  (i)  upon  the 
individual  susceptibilit}^  of  the  nervous  system  of  the 
patient ; (2)  upon  his  constitutional  condition,  and, 
incidentally,  on  the  resisting  power  of  his  tissues;  (3) 
upon  the  action  of  remedies  ; this  being  by  no  means 
the  most  important  consideration. 

The  involvement  of  the  fauces  and  pharynx  charac- 
teristic of  secondary  syphilis,  has  been  explained  upon 
the  ground  of  lymphatic  engorgement,  the  primary 
cause  of  which  is  the  abundance  and  superficial  char- 
acter of  the  lymphatic  capillaries  of  the  affected  parts. 
It  is  a noteworthy  fact,  however,  that  there  is,  but 
little  swelling,  pain  and  tenderness  accompanying  the 
syphilitic  sore  throat,  provided  ulcers  be  absent. 


126 


1 nereis  also,  in  the  early  part  of  the  disease,  little 
or  no  tendency  to  ulceration  in  the  majority  of  cases. 
There  is  comparatively  little  heaping  up  of  syphilitic 
material.  These  characters  would  lead  one  to  sup- 
pose that  there  is  something  behind  the  localized  pro- 
liferation of  cells — if  such  exist — something,  too, 
which  will  explain  the  appearance  of  morbid  phenom- 
ena at  this  particular  point  aside  from  mere  anatom- 
ical pecularities.  For  obvious  reasons  it  has  not  been 
clearly  shown  whether  the  same  efflorescence  and  en- 
gorgement does  not  occur  in  the  other  portions  of  the 
alimentary  canal  in  the  early  period  of  syphilis.  Ad- 
mitting that  there  is  a diffuse  accumulation  of  cells  in 
the  phar3mgo-faucial  tissues,  there  should  be  some- 
thing more  than  local  anatomical  peculiarities  to  ex- 
plain it.  Is  it  not  a result  of  vaso-motor  changes 
similar  to  those  which  prevail  in  the  roseola  and 
which  are  due  to  the  impression  of  the  syphilitic  poison 
upon  the  central  nervous  system  ? The  same  condi- 
tion, in  all  probability,  prevails  in  other  portions  of 
the  alimentary  tract,  which  are,  as  is  well  known,  in- 
timately associated  with  the  sympathetic  nervous  S5’s- 
tem.  If  is  only  at  this  point,  however,  that  the  parts 
affected  are  so  superficial  as  to  be  open  to  observa- 
tion. At  this  point,  moreover,  causes  of  irritation  are 
more  prevalent  than  in  other  portions  of  the  alimen- 
tary tract.  The  food  which  is  swallowed,  rapid 
changes  of  temperature  incidental  to  the  function  of 
respiration  or  to  the  ingestion  of  fluids  at  various  tem- 
peratures ; the  use  of  the  voice,  the  contact  of  irritat- 
ing secretions  from  the  nose  and  the  inhalation  of 
irritating  substances  from  the  atmosphere  might  quite 
rationally  be  expected  to  contribute  to  the  tendenc)' 
to  localization  of  the  sj'philitic  process  in  the  throat. 

In  the  presence  of  such  local  causes  of  irritation, 
vaso-motor  disturbance  incidental  to  the  impression 
of  the  syphilitic  poison  upon  the  central  nervous  s}’s- 
tem  might  be  determined  at  this  point,  while  absent 
in  every  other  situation. 

As  we  have  seen,  the  vaso-motor  impression  which 
underlies  the  development  of  the  roseola  is  substi- 
tuted later  on  for  a more  or  less  pronounced  trophic 
disturbance,  as  manifested  by  the  heaping  up  of  neo- 
plastic^material,  the  development  of  pus,  the  occur- 
rence of  ulcerations,  etc.  Pari  passu  with  the  super- 


127 


vention  of  this  trophic  disturbance  in  the  case  of  the 
skin  we  have  a similar  state  of  affairs  in  the  pharynx 
and  mucous  membrane  of  the  mouth,  as  manifested 
by  the  development  of  mucous  patches,  ulcers,  and 
macular  eruptions,  the  latter  being  particularly  marked 
upon  the  roof  of  the  mouth. 

On  careful  observation  of  successive  crops  of 
lesions  in  syphilis,  it  will  be  found  that  the  tendency 
to  destruction  of  tissue  and  to  the  involvement  of 
various  important  functions  of  the  body  grows  more 
pronounced  as  the  case  progresses.  We  see,  there- 
fore, in  watching  a case  from  its  inception,  the  grad- 
ual supervention  of  a trophic  upon  a vaso-motor  dis- 
turbance, and  as  the  case  progresses  this  trophic 
aberration  becomes  more  and  more  pronounced  until 
finally  in  the  period  of  the  so-called  sequelae  we  have 
marked  destruction  of  tissue  in  various  situations — a 
destruction  so  marked  as  to  have  led  to  the  impres- 
sion at  one  time  that  the  syphilitic  poison  produced 
in  such  instances  corrosion  of  the  tissues.  In  the 
absence  of  a corrosive  power  of  the  syphilitic  poison 
— and  as  we  know  its  infectious  properties  decrease  as 
the  case  progresses — the  only  logical  explanation  of 
the  serious  effects  of  late  syphilis  is  the  theory  of 
tropho-neurotic  disturbance. 

Let  us  glance  at  the  series  of  morbid  phenomena 
in  a typical  case,  and  the  truth  of  the  foregoing  asser- 
tion is  at  once  apparent  : 

First,  we  have  a macular  eruption  or  perhaps  an 
efflorescence  of  the  skin,  which  is  not  at  all  raised 
above  the  surface.  This  (the  roseola)  does  not  pro- 
duce any  destruction  of  tissue.  Later  on  we  have  the 
development  of  papules  ; a little  later  in  the  natural 
order  of  succession,  pustules,  perhaps  followed  by 
ulceration.  Still  later  we  have  rnarked  ulceration  of 
an  echthymatous  or  perhaps  rupial  character ; inter- 
spersed with  these  various  later  lesions  or  occurring 
alone,  we  may  have  a development  of  scaly  lesions — 
sometimes  tubercular  syphilides.  Coincidentally  with 
the  papules  we  have  the  appearance  of  sore  throat,  fol- 
lowed later  on  by  mucous  patches  and  perhaps  ulcer- 
ation. As  the  case  progresses  the  bones  may  be 
affected  ; iritis  may  occur  ; well  along  in  the  period 
of  sequelae,  necrosis  of  the  bones  may  develop.  It 
will  be  found  that  as  the  intensity  of  the  infection 


128 


diminishes,  the  tendency  to  suppurative  processes  and 
to  destruction  of  tissue  increases.  The  later  lesions 
are  found  to  be  frequently  associated  with  disturb- 
ance of  a known  nervous  character,  cerebral  syphilis 
in  its  various  forms  being  quite  apt  to  occur. 

The  exceptions  to  the  gradual  increment  of  severity 
of  syphilitic  lesions  are  so  unusual  that  they  are  now 
designated  as  precocious.  Malignant  or  precocious 
cases  of  syphilis  are  explicable  in  my  opinion  upon 
the  theory  of  idiosyncrasy. 

It  is  in  the  later  secondary  and  sequelar  lesions  of 
the  disease  that  the  apparent  tropho-neurotic  charac- 
ter of  the  manifestations  is  most  pronounced.  I had 
long  been  impressed  with  the  peculiar  course  of  some 
of  the  osseous  lesions  of  late  syphilis,  particularly 
those  affecting  the  head  and  face.  It  had  seemed  to 
me  that  the  destructive  effects  exerted  by  the  morbid 
process  upon  the  bony  tissue,  was  greatly  dispropor- 
tionate to  the  objective  and  subjective  phenomena 
which  preceded  the  actual  destruction. 

For  example,  I think  that  upon  reflection  it  will  be 
found  that  the  objective  morbid  phenomena  wdiich 
precede  the  necrosis  en  masse  of  various  proportions 
of  the  palate,  superior  maxillar}'  and  nasal  bones,  are 
comparatively  slight  when  we  take  into  consideration 
the  fact  that  the  affected  bone  is  entirely  destroyed. 
Indeed,  it  often  seems  that  the  first  objective  phe- 
nomena perceptible  in  cases  of  necrosis  of  the  parts 
mentioned,  is  incidental,  not  to  destruction  of  the  bone, 
but  to  an  attempt  on  the  part  of  nature  to  rid  the  tis- 
sues of  offending  foreign  material.  Thus  I have  ob- 
served cases  in  which  the  greater  portion  of  the  pal- 
ate was  entirely  destroyed,  yet  very  little  manifesta- 
tions of  trouble  were  apparent  until  suppuration  oc- 
curred with  a small  point  of  ulceration  of  the  soft 
parts  covering  the  bone  and  the  discharge  of  a small 
quantity  of  pus — a quantitjq  b3^-the-wa5’,  so  small  as 
to  be  entirely  disproportionate  to  the  extent  of  the 
morbid  process.  On  passing  a probe  into  the  small 
sinus  thus  formed,  one  who  is  not  thoroughly  con- 
versant with  the  peculiarities  of  such  conditions, 
would  quite  likely  be  surprised  to  find  that  a large 
portion  of  the  bone  is  dead  and  perhaps  loose  in  the 
tissues.  It  will  be  found  upon  observation  of  processes 
other  than  syphilitic,  which  produce  necrosis  or 


/:aries  of  bone,  that  there  exists  prior  to  the  death 
of  the  osseous  structure,  quite  pronounced  objective 
phenomena  in  the  way  of  pain,  swelling  and  deformity 
of  the  part,  these  sym.ptoms  indicating  the  existence 
of  proliferated  inflammatory  material  which  subse- 
quently produces,  by  simple  pressure,  destruction  of 
the  vitality  of  the  bone.  Those  morbid  phenomena 
in  sj'philis  which  involve  bone  or  periosteum  in  the 
early  part  of  the  course  of  the  disease  are  accom- 
panied by  relatively  more  prominent  objective  phe- 
nomena than  those  late  lesions  which  are  now  under 
consideration  ; jmt,  at  the  same  time,  thej^  are  rarely 
followed  by  caries  or  necrosis.  These  processes,  it 
seems,  are  reserved  for  the  late  secondary  or  sequelar 
period  of  the  disease.  Thus  it  will  be  seen,  that  al- 
though the  local  process  is  apparently  more  severe  in 
early  cases,  destruction  of  the  vitality  of  the  bone  is 
not  so  likely  to  occur.  There  is  a marked  difference 
between  the  nodes  and  diffuse  subperiosteal  swellings 
of  early  syphilis,  and  the  condition  of  the  bone  and 
periosteum,  which  precedes  necrosis  en  masse,  or  for 
that  matter,  caries,  in  the  late  stages  of  the  disease. 
In  addition  to  the  disproportion  between  the  degree 
of  destruction  of  bone  and  the  objective  phenomena 
preceding  such  destruction,  another  point  worthy  of 
comment,  is  the  fact  that  syphilis  possesses  the  power 
of  dissecting  out  definite  portions  of  osseous  tis- 
sue, apparently  by  cutting  off  their  nutritive  supply 
in  a manner  as  cleanly  as  it  could  be  done  by  the 
knife.  Thus  I have  specimens  in  my  possession  of 
the  intermaxillary  bone,  portions  of  the  alveolar  pro- 
cess of  the  axilla,  the  malar  and  the  ossae  nasi,  which 
became  necrosed,  loosened  and  were  removed  from 
cases  of  late  syphilis.  These  fragments  of  bone  pre- 
sent as  natural  a conformation  in  many  instances  as 
in  their  healthy  condition. 

As  far  as  I have  been  able  to  observe,  there  seems  to 
be  a special  predilection  in  cases  of  late  syphilis  for 
those  parts  supplied  by  the  fifth  nerve,  indicating  that 
the  portion  of  the  sympathetic  system  which  presides 
over  these  parts  is  particularly  sensitive  to  the  syphi- 
litic impression. 

I have  found  in  some  instances  the  tendency  to 
unilateral  destruction  of  osseous  tissue  particularly 
marked.  Thus  the  palatal  process  of  the  superior 


130 


maxilla  upon  one  side,  or  the  superior  alveolus  on  the 
other,  may  necrose  and  give  way  without  the  corres- 
ponding portion  of  bone  becoming  affected.  Indeed, 
it  seems  that  in  most  instances  in  which  necrosis  at- 
tacks the  bones  of  the  face,  it  is  impossible  to  check 
the  process  until  the  line  of  demarkation  represented 
by  the  anatomical  outline  of  the  affected  bone  has 
been  reached. 

The  peculiar  manner  in  which  one-half  of  a struc- 
ture may  be  dissected  away  by  the  sequelar  lesions  of 
syphilis,  is  exemplified  by  a case  of  syphiloma  of  the 
tongue  which  recently  came  under  my  observation  in 
which  the  sloughing  of  the  organ  was  limited  to  the 
raphe.  This  case  subsequently  went  on  to  malignant 
transformation.  I removed  the  tongue  by  the  gal- 
vano-cautery,  the  disease  recurred,  and  the  patient 
died  of  hemorrhage  several  months  later.* 

I have  had  several  cases  recently  in  which  that  por- 
tion of  the  superior  maxilla  corresponding  to  the  in- 
termaxillary bone  v/as  dissected  out  b}^  the  syphilitic 
process  with  the  resultant  loss  of  the  incisor  teeth, 
the  remainder  of  the  jaw  remaining  intact.  There 
appears  to  be  a peculiar  predilection  of  late  syphilis 
for  this  portion  of  the  jaw.  I have  seen  several  cases 
in  which  caries  occurred  in  this  situation  with  a con- 
sequent loss  of  one  or  more  perfectly  health}'’  teeth. 
These  cases  have  appeared  to  me  to  be  so  character- 
istic that  I have  come  to  regard  loss  of  the  incisor 
teeth  without  any  apparent  cause  as  almost  positive 
evidence  of  syphilis. 

An  interesting  case  illustrating  the  unilateral  limita- 
tion of  some  late  lesions  of  S3'philis  came  under  my 
observation  recentl}c 

The  patient  was  a gentleman  who  had  an  obscure 
histor}'  of  S3'philis,  dating  some  3'ears  back.  Several 
weeks  before  coming  under  my  observation,  ulceration 
began  at  the  roots  of  the  molar  teeth  upon  one  side 
and  extended  outward  to  the  palate.  When  I first 
saw  the  case  the  ulceration  had  extended  outward 
upon  the  hard  palate  for  about  three-quarters  of  an 
inch  and  forward  to  the  median  line,  when  it  abrupti}' 
stopped.  The  appearance  of  the  ulceration  was  quite 
t3'pical.  There  was  no  disease  of  the  teeth  or  jaws  to 

Apparent  Cancerous  Transformation  of  Syphiloma  of  the 
Tongue — Amputation  by  the  Galvano-Cauter}'.  A . T.  Medical 
Record,  Oct.  26,  1889, 


account  for  it.  Healing  was  quite  rapid  under  appro- 
priate anti-s5'philitic  treatment. 

Another  interesting  case  of  a somewhat  similar 
character  ; 

The  patient  was  a gentleman  who  had  s}'philis 
seven  or  eight  }^ears  ago.  For  the  last  three  or  four 
years  he  has  had  occasional  symptoms  of  the  disease. 
A few  months  since  ulceration  occurred  about  the 
roots  of  'the  upper  incisor  teeth  and  was  attended 
with  slight  caries  of  the  intermaxillary  bone.  The 
process  was  checked  by  appropriate  treatment,  the 
teeth,  which  were  loosened,  finally  becoming  perfectly 
solid.  About  six  or  eight  weeks  after  the  ulceration 
was  healed  the  patient  consulted  me  for  supra  and 
infra-orbital  neuralgia  and  hemicrania.  This  resisted 
all  treatment  except  anti-syphilitic  remedies.  It 
yielded  readily  to  iodide  of  potassium  in  large  doses. 
Within  a few  days  the  patient  has  again  consulted  me 
for  parsesthesia  of  the  right  side  of  the  face,  which  he 
noticed  for  the  first  time  while  being  shaved.  His 
face  having  been  excessively  tender  previousl}',  he 
very  speedily  noticed  a lack  of  sensibility  under  the 
razor.  Associated  with  this  paraesthesia  there  is 
obscure  pain  which  he  locates  back  of  the  eyeball. 
The  ensemble  of  symptoms  in  this  case  points  to  cen- 
tral disturbance  and  evidence  a manifest  predilection 
of  the  sequelar  lesion  for  the  fifth  cranial  nerve. 

The  association  of  obstinate  tubercular  syphilides 
with  nervous  s}'philis  is  well  known.  It  seems  that 
the  danger  of  involvement  of  the  central  nervous  sys- 
tem is  directly  proportionate  to  that  of  severe  syph- 
ilides. 

In  considering  the  tropho-neurotic  character  of  the 
late  lesions  of  syphilis,  I do  not  ignore  the  fact  that 
S5'philis  may  act  directly  upon  the  nervous  system  in 
several  different  ways  : 

1.  By  the  direct  effect  of  syphilitic  deposit  upon 
the  serve  cells  or  fibers,  or  membranes  of  the  brain 
and  spinal  cord. 

2.  By  changes  in  the  membranous  envelopes  of 
the  brain  and  spinal  cord. 

3.  By  deposits  in  and  about  the  blood  vessels 
which  induce  circulatory  disturbance. 

4.  By  a proliferation  and  condensation  of  connect- 
ive tissue  which  remains  after  the  syphilitic  materia] 
per  se  has  been  removed. 


132 


There  is  probably  a difference  in  the  late  and  early 
forms  of  syphilitic  lesions  in  the  manner  in  which  the 
tropho-neurotic  element  is  brought  about.  Thus  it 
may  be  due  in  the  first  place,  to  a direct  impression 
of  the  syphilitic  poison  upon  the  sympathetic  nervous 
system.  Secondly,  upon  direct  pressure  upon  the 
nervous  structures.  Thirdly,  upon  a disturbance  of 
function  and  nutrition  of  the  nervous  structures  inci- 
dental to  interference  with  blood  supply. 

It  is  probable  that  mercury  acts  upon  the  nervous 
system  in  ver}^  much  the  same  manner  as  does  S}'ph- 
ilis.  It  is  very  difficult  to  differentiate  late  syphilitic 
lesions  of  the  bones  and  of  the  mucous  membranes 
from  those  directly  due  to  the  action  of  mercury. 
That  mercury  exerts  a powerful  effect  upon  the  s}un- 
pathetic  nervous  system  is,  it  seems  to  me,  shown 
conclusively  by  the  phenomena  of  ptyalism,  which 
cannot  be  accounted  for  solely  upon  the  theory  of  the 
production  of  irritation.  The  well-known  power  of 
mercury  over  the  secretions  is  probabl}'  due  to  its 
influence  upon  the  sympathetic  ganglia.  When  the 
injurious  action  of  mercury  is  superadded  to  syphilis, 
there  is  a more  marked  tendency  to  tropho-neurotic 
phenomena  than  in  well-treated  cases  of  the  disease. 
Indeed,  the  excessive  use  of  mercury  often  seems  to 
determine  the  predilection  of  late  syphilis  for  the 
bones  of  the  head  and  face.  It  is  quite  as  capable  of 
producing  necrosis  or  destructive  ulceration  of  these 
parts,  as  is  syphilis  per  se. 

Positive  demonstration  of  the  dependence  of  the 
phenomena  which  I have  outlined  upon  nervous  dis- 
turbance, is  of  course  difficult,  but  the  inferences 
which  I have  drawn  appear  to  me  to  be  logical.  In 
considering  the  question  of  trophic  disturbances  in 
their  relation  to  destructive  syphilitic  processes  it  is 
well  to  remember  the  familiar  ph5'siological  experi- 
ment of  section  of  the  sympathetic  in  the  neck  of  the 
rabbit.  The  same  experiment  is  also  interesting  as  bear- 
ing upon  the  faucial  congestion  of  early  syphilis.  The 
reddening  of  the  ear  of  the  rabbit,  the  inflammation 
and  sloughing  of  the  cornea  incidental  to  section  of 
the  sympathetic  are  certainly  suggestive.  To  carr}' 
the  analogy  of  this  physiological  demonstration  a 
little  further,  I w’ould  call  attention  to  the  serious 
corneal  trouble  which  sometimes  results  from  herpes 
frontalis  sen  orbicularis. 


A REIVIEIW  OF 

Varicocele  and  Its  Treatment.* 


Varicocele  in  a general  wa}',  may  be  said  to  be  one 
of  the  most  frequent  surgical  diseases  of  the  male 
genito-urinary  apparatus.  If  however  we  take  into 
consideration  only  those  instances  in  which  the  disease 
is  sufficiently  marked  to  demand  the  attention  of  the 
surgeon,  the  number  of  cases  is  greatly  reduced.  Vari- 
cocele is  not  an  intrinsically  serious  affection,  but  from 
certain  circumstances  peculiar  to  its  location  and  the 
importance  of  the  function  of  the  involved  part,  there 
is  nevertheless  a fair  proportion  of  cases  in  which  the 
patient  sooner  or  later  consults  the  surgeon.  There 
are  few  diseases  of  so  mild  a character  pe?-  se  that  are 
capable  of  causing  so  much  annoyance  to  the  patient 
as  is  varicocele. 

To  be  sure  the  annoyance  is  more  often  of  a mental 
than  physical  character,  but  to  my  mind  this  very  fact 
is  a warrant  for  more  careful  consideration  than  is 
usually  accorded  it.  It  is  not  every  patient  whom  we 
can  convince  that  the  condition  is  a very  trifling  matter. 

In  some  cases  there  are  urgent  physical  reasons  for 
most  careful  consideration  of  the  disease. 

*Read  in  abstract  before  the  Southern  Surgical  and  Gynae- 
cological Association.  Atlanta,  Ga.,  Nov.  12,  1890. 


i34 


Varicocele  consists  of  a dilatation  of,  with  accom- 
panying structural  changes  in,  the  walls  of  the  plexus 
of  veins  surrounding  the  spermatic  cord.  These 
changes  are  the  same  as  those  which  occur  in  varix 
in  other  situations  ; the  causes  being  also  essentially 
the  same  if  we  exclude  masturbation  and  sexual  ex- 
cesses. 

The  term  varicocele  is  not  very  definite,  inasmuch 
as  it  literally  implies  a varicose  enlargement  of  the 
veins  in  any  situation.  Etymologically,  the  inaccu- 
racy of  the  nomenclature  of  the  special  form  of  vari- 
cocity  under  consideration,  is  quite  evident. 

The  word  varicocele  (fr.  varix=a  dilated  vein-fi^wO/ 
=a  tumor)  is  an  awkward  but  convenient  hybrid. 
Cirsocole  (incorrectly  circocele  xipdoz=‘A.  \'ar\x-\-xn,{>i 
a tumor),  is  more  elegant  and  perhaps  more  correct, 
but  is  almost  obsolete.  Both  words  from  an  etymo- 
logical standpoint  signify  a varicose  swelling  in  an}' 
portion  of  the  body,  but  clinical  usage  has  restricted 
them  to  the  scrotal  region.  Pott  suggested  the  term 
cirsocele  for  varicose  veins  in  the  scrotum,  and  vari- 
cocele for  a similar  condition  of  the  veins  of  the  sper- 
matic cord,  but  at  the  present  day  the  former  term  is 
rarely  met  with  in  English  medical  works  or  period- 
icals. 

The  frequency  of  i^aricocele  is  a matter  of  some  doubt, 
statistics  varying  greatly.  The  wide  variation  in  esti- 
mates is  doubtless  due  to  the  varying  interpretation 
of  the  term  varicocele  by  different  observers,  and  to 
the  varying  classes  among  whom  the  observations  are 
made.  Landouzy,  an  old  Erench  writer,  put  the  pro- 
portion of  cases  at  GO  per  cent  of  adult  males. 

This  is  undoubtedly  an  exaggeration  due  to  the 
classification  of  the  slighter  forms  of  dilatation  of  the 
spermatic  veins  as  varicocele. 

Henry  found  but  forty-one  cases  in  nearly  twm 
thousand  men  examined  for  the  New'  York  police 


*"  Du  varicocele  et  en  particulier  de  la  cure  radicale  de  cette 
affection.” 


135 


force*.  This  record  is  however  not  an  accurate  crite- 
rion of  the  frequency  of  varicocele,  as  applicants  for 
the  metropolitan  police  force  are  exceptionally  vigor- 
ous, and  by  no  means  the  class  predisposed  to  the 
disease.  My  own  observations,  comprising  a large 
number  of  life  insurance  examinations,  as  well  as  a 
large  number  of  patients  seen  in  private  and  dispensary 
practice,  show  that  not  to  exceed  5 per  cent  of  male 
adults  have  varicocele,  of  even  moderate  dimensions. 
The  proportion  of  cases  which  are  marked  enough  to 
cause  definite  symptoms  is  even  smaller. 

Varicocele  often  tends  to  diminish  with  advancing 
age.  M.  Horteloup,  surgeon  to  the  Bicdtref  found 
42  subjects  with  varicocele  among  1,000  individuals, 
and  of  these  16  had  developed  before  the  age  of  twenty- 
five.  Of  the  total  number  of  cases  14  increased,  19 
remained  stationary,  8 diminished  and  one  entirel}' 
disappeared  at  the  age  of  4.5.  Of  the  cases  which  ap- 
peared before  the  age  of  25,  eleven  increased  or  re- 
.mained  stationary,  four  diminished  and  one  disap- 
peared. These  figures  show  that  while  varicocele  does 
not  necessarily  progress,  an  increase  is  to.be  antici- 
pated in  a fair  proportion  of  cases.  The  prognosis  is 
rendered  more  favorable,  however,  if  we  consider  the 

class  of  patients  on  whom  these  observations  were  made. 

The  occupants  and  out  patients  of  the  Bicetrd  are 
nearly  all  engaged  in  hard  manual  labor.  As  Horte- 
loup remarks  in  connection  with  the  indications  for 
treatment;  the  surgeon  must  be  guided  in  his  prac- 
tice by  the  social  status  of  the  patient.  Palliation 
may  effectually  prevent  increase  of  the  varicocle  in 
the  wealthier  class  of  patients,  yet  prove  ineffectual 
among  laborers  and  those  subjected  to  prolonged 
standing.  Vidal  has  laid  especial  stress  upon  this 
point  ; 

Varicocele  is  more  frequent  than  varices  elsewhere 
from  the  fact  that  there  exists  not  only  general  but 


■"■"The  treatment  of  varicocele,"  1889. 
tMemoire  a I’Acad.  inedit. 


136 


also  special  causes  of  venous  dilation  due  to  local  an- 
atomical conditions.  The  veins  are  relatively  large, 
and  follow  a devious  course  along  the  spermatic  cord, 
forming  a peculiar  plexus  (pampiniform)  about  this 
structure;  the  vessels  of  this  plexus  frequently  anas- 
tomose. The  valves  of  these  vessels  are  few  in  num- 
ber, very  defective  and  yield  to  the  downward  pres- 
sure of  injected  fluid  very  readily.  As  compared  with 
the  veins  in  other  locations  those  of  the  pampiniform 
plexus  are  poorly  supported  by  connective  tissue 
which  is  in  this  situation  sparse,  loose  and  inelastic. 
The  spermatic  veins  are  very  long  and  independent!}' 
of  defective  valves,  there  is  a marked  tendency  to 
yielding  of  the  illy-supported  venous  walls,  to  the 
weight  of  the  long  column  of  blood  which  flows  so 
nearly  perpendicularly  upward.  Pressure  upon  the 
veins  as  they  traverse  the  inguinal  canal  tends  to  en- 
hance the  prospect  of  varicocele.  Strains  of  the  ab- 
dominal wall  and  especially  those  involved  in  difficult 
defecation  are  likely  to  bring  this  about. 

Varicocele  has  been  a subject  of  some  importance  to 
military  surgeons,  especially  as  regards  examinations 
for  enlistment.  Landouzy  states  that  of  166,317  men 
examined  in  England  and  Ireland  during  a series  of 
years,  70.5  per  cent  were  exempted  from  service  on  ac- 
count of  varicocele,  'i'he  Army  Medical  Reports  of 
Great  Britain  are  quoted  as  stating  that  during  the 
years  from  1869  to  1873,  of  331.568  men  examined, 5, 312 
were  rejected  for  varicocele.  Sistach,  in  1863,  asserted 
that  in  France,  11  per  1,000  of  candidates  were  reject- 
ed for  varicocele.  From  1879  to  1883  the  proportion 
had  been  reduced  to  3 per  1000.  It  is  claimed  that 
this  reduction  was  due  to  improved  methods  of  treat- 
ment, but  this  is  probably  an  exaggerated  estimate  of 
surgical  progress.  Horteloup  relates  a case  that  was 
rejected  on  account  of  varicocele,  in  which  the  candi- 
date was  accepted  without  comment  after  a success- 
ful operation. 

Varicocele  is  most  freqtient  upon  the  left  side,  the 
reasons  advanced  therefor  being  : 1. — The  relative- 


137 


ly  lower  position  of  the  left  testis.  2. — The  relative 
acuteness  of  the  angle  formed  by  the  junction  of  the 
left  spermatic  with  the  renal  vein.  3. — The  close 

proximity  of  the  left  spermatic  vein  to  the  sigmoid 
flexure  of  the  colon  and  its  consequent  exposure  to 
pressure  in  constipation.  4. — The  absence  of  a valve 
in  the  left  spermatic  vein  at  its  junction  with  the  re- 
nal. 5. — The  tendency  of  men  to  stand  upon  the  left 
foot. 

It  would  appear  that  the  relatively  greater  length 
of  the  cord  and  its  attendant  vascular  structures  with 
the  consequent  greater  weight  of  the  contained  col- 
umn of  blood  upon  the  left  as  compared  with  the  right 
side,  is  an  all-sufficient  explanation. 

When  varicocele  is  present  on  the  right  side  there 
is  almost  invariablj^  involvement  of  the  left  side  also; 
— indeed,  I do  not  recall  a case  in  which  the  right 
side  alone  was  involved.  Traumatic  causes  may, 
however,  give  rise  to  such  a condition.  The  rela- 
tively greater  frequency  of  varicocele  on  the  left  side 
was  expatiated  upon  by  Celsus,  hence  there  has  been 
plenty  of  time  for  an  abundant  crop  of  explanations 
to  develop. 

The  causes  of  varicocele  are  several  ; First  and  most 
important  is  a constitutional  lack  of  tone — this  cause 
is  rarely  accorded  sufficient  importance,  the  tendeney 
being  to  seek  for  exclusively  local  causes.  What  is 
termed  congenital  or  hereditary  predisposition  to 
varixin  general,  consists  of  an  inherent^lack  of  mus- 
cular and  vascular  tonicity.  The  venous  walls  are 
especially  weak  and  flabby,  and  the  circulation  slug- 
gish. The  same  causes  that  produce  laxity  of  the 
venous  walls  produce  feeble  heart  action  ; there  is  a 
deficiency  in  the  vis  a tergo  which  is  so  important  in 
propelling  the  blood  through  the  veins,  and  also  a 
deficiency  in  the  aspirating  power  of  the  heart  and 
lungs.  The  association  of  these  conditions  with  vari- 
ces of  the  extremities  will  on  reflection  be  found  to  be 
very  familiar.  These  same  patients  present  a special 
tendency  to  hemorrhages  on  account  of  vaso  motor 


deficiency,  and  I have  noticed  in  a general  way  that 
the  existence  of  varices  of  the  extremities  in  patients 
about  to  be  operated  upon,  is  a note  of  warning  as 
regards  possible  annoyance  from  hemorrhage. 

Persons  who  suffer  from  such  diseases  as  purpura 
and  scurvy  are  peculiarly  liable  to  relaxed  and  dilated 
conditions  of  the  veins.  Strumous  individuals  also 
present  a tendency  to  varices. 

Varices  are  apt  to  occur  in  persons  of  indolent 
habits,  because  of  defective  circulation  as  well  as  a 
general  lack  of  tone  with  resulting  vascular  flabbiness 
incidental  to  insufficient  exercise.  Such  persons,  who 
are  compelled  to  stand  at  their  work  for  prolonged 
periods  are  peculiarly  subject  to  varicose  veins.  Cer- 
tain diseases  of  the  heart,  liver,  lungs,  and  peritoneal 
cavity,  which  produce  by  pressure,  retardation  of  the 
return  flow  through  the  inferior  vena  cava  and  iliac 
veins,  favor  the  development  of  varix.  Longstanding 
portal  obstruction  is  liable  to  produce  varicocele  in 
conjunction  with  hemorrhoids. 

Masturbation,  sexual  excesses  and  prolonged  vene- 
real excitement  without  gratification  are  undoubtedl)' 
responsible  for  varicocele  in  many  instances.  I re- 
gard it  as  highly  improbable  that  these  causes  if 
brought  to  play  for  the  first  time  in  a healthy  adult, 
would  cause  varicocele,  but  occurring  as  they  usuall)' 
do  when  tissue  development  is  reall)^  in  excess  as 
compared  with  the  inherent  resisting  power  of  the 
various  structures,  the}'^  operate  ver}'  powerfulh'^  in 
producing  congestion  and  finally  dilatation  of  the 
spermatic  plexus.  It  will  be  found  that  in  a large 
proportion  of  cases  which  seem  to  be  attributable  to 
these  causes  there  exists  a foundation  for  the  disease 
in  the  form  of  an  inherentl}'^  defective  tone  of  the  vas- 
cular walls,  akin  perhaps  to  that  mysterious  condition 
which  exists  in  haemophilia  as  far  as  its  hereditary 
character  is  concerned. 

Inasmuch  as  it  is  an  established  fact  that  this  dis- 
ease is  of  an  hereditary  character  and  to  a great  ex- 
tent dependent  upon  defective  arterial  contractilit3g 


*39 


it  is  fak  to  assume  that  a similarly  defective  tone  of 
the  venous  walls  may  exist.  A case  has  recently 
come  under  my  observation  which  illustrates  in  a 
forcible  manner  the  association  of  perverted  vascular 
tone  and  blood  quality  with  varicocele.  An  epileptic 
was  referred  to  me  by  Dr.  S.  V.  Clevinger  for  consul- 
tation. This  man  had  a very  large  varicocele  which 
annoyed  him  greatly,  the  chief  complaint  being  that 
the  profuse  perspiration  which  bathed  the  part  was 
almost  constantly  of  a sanguineous  character.  The 
patient  informed  me  that  his  seminal  ejaculations 
were  always  heavily  tinged  with  blood. 

My  friend  Dr.  F.  W.  McRae,  of  Atlanta,  Ga.,  has 
described  a similar  case  to  me,  in  which  the  scrotal 
hmmidrosis  was  quite  distinct.  These  cases  are  the 
only  examples  of  this  peculiar  condition  which  have 
come  under  my  observation.  As  an  illustration  of 
the  fact  that  vaso  motor  aberration  existed  in  my  case, 
I will  state  that  I operated  upon  the  patient  for  stric- 
ture and  had  a very  alarming  hemorrhage  to  deal 
with,  which  persisted  for  several  days.  From  what 
has  been  said  it  is  evident  that  varicocele  is  usually 
met  with  in  comparatively  feeble  subjects.  Occasion- 
ally from  some  special  cause  involving  trauma,  robust 
individuals  are  affected  by  it.  Spencer  has  advanced 
the  novel  theory  that  varicocele  is  due  to  the  persist- 
ence of  foetal  veins  which  ordinaril}?  undergo  complete 
involution  during  childhood. 

Varicocele  has  been  known  to  occur  from  heavy 
lifting  and  athletic  strain  of  various  kinds.  I have 
seen  several  cases  which  were  probably  of  this  origin. 
Keyes  describes  this  variet}' : Years  ago,  Percival 

Pott  described  what  he  termed  “acute  varicocele” 
due  to  a combination  of  fatigue,  injury  to  the  part 
and  exposure  to  cold,  the  condition  being  followed  b}' 
complete  atrophj'  of  the  testis.  These  cases  were 
probably  phlebitis  of  the  spermatic  plexus  which  was 
followed  by  complete  occlusion  of  their  lumen. 
Orchitis  was  possibly  an  attendant  condition. 

Excessive  horseback  riding  is  a fertile  source  of 


140 


varicocele — an  occasional  blow  from  the  pommel  of 
the  saddle  being  a secondary  but  by  no  means  unim- 
portant consideration.  Varicocele  from  this  cause  is 
especially  apt  to  be  associated  with  hemorrhoids. 
The  records  of  the  pension  office  are  very  interesting 
in  this  connection. 

Chronic  constipation  is  regarded  by  many  surgeons 
as  a very  fertile  source  of  varicocele  ; this  I accept, 
providing  the  constitutional  defect  already  described 
be  associated  with  it.  Constipation  alone,  I believe 
to  be  insufficient  to  produce  varicocele.  The  pressure 
of  accumulated  faeces  upon  the  left  spermatic  vein 
tends  to  retard  the  return  circulation,  and  if  the 
venous  walls  be  naturally  defective,  varicocele  ma)' 
result.  The  pressure  of  a truss  sometimes  produces 
varicocele  in  conjunction  with  a hernia  ; indeed,  the 
pressure  of  a hernia  itself  has  been  alleged  to  cause 
varicocele.  This  is  worthy  of  note,  inasmuch  as  the 
application  of  a truss  for  the  cure  of  varicocele  is 
recommended  by  several  excellent  authorities,  as  will 
be  seen  later.  It  is  to  be  remembered  in  connection 
with  the  etiology  of  varicocele  that  constitutional  de- 
bility may  bear  the  relation  to  the  disease,  of  both 
cause  and  effect. 

Varicocele  occurs  with  the  greatest  frequency  between 
the  ages  of  fifteen  and  thirty-five,  this  being  the 
period  when  all  the  faculties  of  the  body  are  at  their 
maximum  and  physical  growth  is  most  active ; or 
better,  this  is  the  period  when  there  is  a degree  of 
growth  far  in  excess  of  the  inherent  strength  of 
tissue. 

It  is  at  this  period  also,  that  perverted  sexual  hab- 
its and  hygiene  are  apt  to  enter  into  the  daily  life  of 
the  patient,  either  in  the  form  of  sexual  excess,  sexual 
excitement  without  gratification,  or  most  frequently, 
masturbation.  It  is  at  this  age  that  men  are  most 
likely  to  overtax  their  strength;  then  too  the  effects 
of  exhaustion  are  most  severe,  especially  near  the 
period  of  pubert3n  Varicocele  is  occasionallj'  met 
with  in  young  children,  and  in  such  cases  there  is  not 


oaly  a pronounced  atonicity  of  vascular  structure  in 
general,  but  evidences  of  sexual  precocity.  In  certain 
rare  instances  it  has  been  known  to  occur  after  mid- 
dle life,  in  which  event  there  is  a decidedly  dispropor- 
tionate varicocity  of  the  scrotal  veins. 

The  morbid  anatomy  of  varicocele  comprises  few 
changes  of  importance.  The  pathological  changes 
consist  mainly  in  dilatation  and  tortuosity  of  the  veins 
with  a coincident  loss  of  elasticity  and  contractility. 
There  is  usually  more  or  less  increase  in  the  thickness 
of  the  venous  walls.  This,  however,  does  not  make 
the  vessels  proportionately  stronger  because  of  the 
fact  that  the  vessels  are  enormously  dilated,  and  their 
walls  are  consequently  much  thinner  in  proportion  to 
the  bulk  and  weight  of  the  contained  blood  than  is  the 
case  with  normal  vessels.  Not  only  are  the  elastic  and 
contractile  elements  of  the  vascular  walls  absorbed  in 
pronounced  varicocele,  but  they  are  replaced  by  a low 
grade  of  connective  or  fibro-connective  tissue.  These 
conditions  enhance  the  structural  weakness.  Suba- 
cute or  chronic  inflammatory  changes  may  occur  and 
cause  primarily  still  further  thickening,  and  secondari- 
ly a more  pronounced  degree  of  degeneration  of  the 
vessels.  As  a consequence  of  these  conditions  of  in- 
nutrition, areas  of  fatty  degeneration  may  develop. 

These  degenerated  areas  explain  the  occasional  oc- 
currence of  hasmatocele  of  the  scrotum  from  slight  ex- 
citing causes  in  pronounced  varicocele.  Acute  phle- 
bitis may  attack  varicocele  and  prove  a serious  mat- 
ter. Vidal  de  Cassis  reported  two  cases  of  this  kind, 
one  due  to  a kick  and  the  other  to  propagation  of  in- 
flammation from  an  acute  epidymitis.  Plaques  of  cal- 
cific deposit  may  be  observed  in  some  cases  and  phle- 
boliths  are  by  no  means  rare;  oftentimes  these  con- 
cretions may  be  felt  from  the  exterior.  The  valves  of 
the  involved  veins  are  a dead  letter  as  far  as  their 
functionating  capacity  is  concerned;  so  degenerated 
do  they  become  that  they^  present  the  appearance  of 
rudimentary  valves  in  other  situations. 

The  testicle  of  the  affected  side  rarely  retains  its 


142 


structural  integrity;  but  becomes  softer  than  normal, 
shrunken  and  atrophied;  in  severe  cases  it  may  be 
difficult  to  detect  amidst  the  worm  like  mass  of  veins. 
There  is  of  course  no  method  of  determining  its  func- 
tional power  with  any  degree  of  accuracj",  excepting 
where  the  opposite  testicle  is  out  of  service,  but  the 
ph}'sical  condition  of  the  organ  is  a very  fair  criterion 
of  its  physiological  activity.  The  cutaneous,  muscu- 
lar and  serous  envelopes  of  the  testis  participate  in 
the  general  and  local  lack  of  tone,  and  the  veins  of  the 
organ  proper  become  dilated  and  varicose.  The  scro- 
tum is  lax,  thinned  and  pendulous  and  on  section  the 
fibres  of  the  dartos  muscle  will  be  found  to  be  sparse  and 
fragile.  Elastic  tissue  is  also  much  scantier  than  normal. 

In  general,  the  cutaneous  structure  proper  is 
thinner  and  more  distensible  than  in  its  normal  con- 
dition. The  scrotal  veins  are  dilated,  tortuous  and 
thinned,  their  varicocity  in  some  cases  being  quite 
remarkable.  This  condition  of  the  veins  is  an  addi- 
tional evidence  of  the  general  lack  of  vascular  tonicity. 

Verneuil  describes  two  cases  of  erectile  venous 
tumors  of  the  scrotum  associated  with  varicocele, 
which  showed  a marked  tendency  to  spontaneous 
inflammation.  Escallier  reported  two  similar  cases 
which  spontaneously  underwent  suppuration,  with  a 
fatal  result.  In  most  cases  the  anterior  spermatic 
plexus  is  alone  involved  primarily,  the  posterior 
plexus  however,  becoming  involved  later  in  man}' 
cases.  Sometimes  it  only  is  involved. 

The  Symptoms  of  varicocele  are  in  the  main  so  famil- 
iar that  their  description  is  only  necessary  for  com- 
pleteness. They  necessarily  vary  according  to  the 
severity  of  the  varix.  The  first  thing  to  attract  the 
attention  of  the  patient  is  usuall}'  enlargement  of  the 
veins,  producing  as  the  patient  erroneously  supposes, 
a slightly  tumorous  condition  of  the  testicle.  This 
enlargement  is  in  many  cases  so  slight  that  it  is  of 
no  practical  importance,  and  should  hardly  be  des- 
ignated as  a varicocele  ; its  principal  effect  in  such 
cases  being  a greater  or  less  disturbance  of  the  morale 


143 


of  the  patient.  Those  individuals  who  consult  the 
surgeon  regarding  the  slighter  forms  of  varicocele  are 
usually  masturbators  who  have  become  aware  of  the 
possible  evil  effects  of  the  practice  and  who,  under 
the  stimulus  of  quack  literature  are  practicing  a most 
rigid  introspection  and  frantically  searching  for  mor- 
bid effects  of  their  vicious  habits.  In  their  daily 
inspection  of  the  genitals  these  patients  discover  a 
slight  enlargement  of  one  or  the  other  testicle. 
Possibly  at  this  time  their  attention  is  first  called  to 
the  fact  that  one  testicle  hangs  lower  than  the  other. 
The  discovery  of  this  condition  in  combination  with 
guilty  self-consciousness  impels  the  patient  to  seek 
relief  ; only  too  often  he  consults  the  quack,  who  finds 
in  such  patients  his  richest  harvest.  Should  pollu- 
tions or  spermatorrhoea  be  present,  then  indeed  is  the 
quack  in  clover. 

These  slight  enlargements  of  the  spermatic  veins 
are  due  to  imperfect  sexual  hygiene  with  attendant 
venous  congestion  and  should  be  called  spermatic  con- 
gestion, rather  than  dignified  by  the  term  varicocele 
They  generally  disappear  after  normal  sexual  relations 
have  been  established,  and  it  is  rare  for  such  patients  to 
consult  the  surgeon  after  they  have  once  been  happily 
married.  Operative  interference  in  these  cases  is  usu- 
ally unwarrantable.  Even  in  these  slight  cases,  however, 
there  may  be  neuralgic  symptoms  of  sufficient  sever- 
ity to  warrant  treatment,  both  general  and  local. 

Varicocele  in  its  more  marked  form  is  readily  rec-  ^ 
ognizable.  It  presents  a soft,  mushy  tumor,  which 
is  ordinarily  said  to  resemble  a bunch  of  earth-worms 
in  a sac.  This  description  is  very  accurate,  as  every 
surgeon  knows.  The  veins  of  the  scrotum  are  very 
often  tortuous  and  dilated.  Varicocele  is  not  sup- 
posed to  be  tender  on  pressure,  but  if  phlebitis  exists 
or  there  is  severe  neuralgia  of  the  testicle  and  cord, 
the  part  is  apt  to  be  extremely  hyper^sthetic.  In  the 
majority  of  advanced  cases  the  testicle  is  not  only 
atrophied,  but  is  extremely  insensitive  to  touch  or 
even  pressure.  Phleboliths  may.be  detected  within 


144 


the  veins  and  may  perhaps  be  the  centers  of  inflam- 
matory changes  and  consequent  tenderness. 

The  siibjective  symptoms  of  varicocele  vary  greatly; 
this  is  especially  true  of  those  of  a mental  character. 
A case  of  moderate  varicocele  in  which  the  mind  of 
the  patient  has  not  been  disturbed  by  quack  literature 
or  the  rigid  introspection  induced  by  a knowledge  of 
the  evils  of  masturbation  is  apt  to  cause  little  or  no 
inconvenience.  In  nearl}'  all  well  marked  cases,  how- 
ever, the  conditions  are  decidedly  unfavorable  to 
mental  composure  and  a greater  or  less  degree  of 
ph3’sical  suffering  is  almost  inevitable.  The  testicle 
is  an  extremely  sensitive  organ  and  its  nervous  supplj'^ 
is  so  closely  associated  with  the  great  sympathetic 
system  that  diseases  affecting  its  structure  might 
rationally  be  expected  to  produce  general  nervous 
disturbance  as  well  as  pronounced  local  symptoms. 
The  painful  and  depressing  character  of  orchitis  and 
epididymitis  is  sufficient  to  show  that  d'sturbances  of 
the  testicle  are  productive  of  a disproportionate 
degree  of  general  disturbance.  This  is  characteristic 
of  all  diseases  of  the  sexual  apparatus — we  all  know 
what  serious  symptoms  may  follow  a phimosed  pre- 
puce or  a contracted  meatus.  If  these  slight  affec- 
tions produce  such  affects,  how  much  more  likelj'^  is 
varicocele  to  cause  great  annoyance  from  the  constant 
dragging  upon  so  sensitive  a structure  as  the  sper- 
matic cord  and  the  incidental  congestion  of  a still 
more  sensitive  testicle.  I speak  of  these  points  more 
particular!}^  because  most  surgeons  are  inclined  to  be- 
lieve that  all  of  the  symptoms  described  b}'^  the  sub- 
jects of  varicocele,  are  imaginary.  This  belief  is 
hardly  consistent  with  our  physiological  and  anatomi- 
cal knowledge,  yet  it  prevails  even  among  those  who 
would  sacrifice  an  ovary  upon  the  slightest  pretext. 
It  might  be  a good  plan  for  the  practitioner  to  learn 
more  of  the  reflex  and  other  phenomena  dependent 
upon  morbid  conditions  of  the  male  sexual  apparatus, 
the  more  especially  as  the  consideration  of  a method 
of  treatment  similar  to  that  advocated  indiscrimin- 


ately  in  certain  quarters,  for  the  female,  would  save 
a few  bushels  of  ovaries  and  appendages.  It  is  safe 
to  say  moreover,  that  not  a testicle  would  be  lost. 

In  the  majority  of  cases  of  pronounced  varicocele  a 
greater  or  less  degree  of  mental  depression  and  sex- 
ual hypochondriasis  exists,  and  in  certain  instances 
serve  to  make  life  miserable.  Vidal  has  called  atten- 
tion to  the  fact  that  suicidal  impulses  are  occasionally 
observed  in  the  subjects  of  varicocele.  He  notes  the 
case  of  a hospital  physician  who  told  him  that  he  had 
decided  to  blow  his  brains  out  in  case  he  could  not  be 
promised  a cure.  If  the  tumor  be  very  large  and  the  pa- 
tient sensitive  the  physical  deformity  may  cause  great 
annoyance.  This  was  most  marked  in  one  of  my  cases. 

Whether  as  a coincidental  effect  of  a similiar  cause 
or  as  an  effect  of  the  varicocele  per  se,  there  exists  in 
nearly  every  case  of  severe  varicocele  a decided  loss 
of  tone  of  the  sexual  apparatus.  The  symptoms  indi- 
cative of  this  are  in  my  estimation  often  directly  de- 
pendent upon  the  varicocele.  Pseudo  impotence,  fre- 
quent pollutions  and  spermatorrhoea  are  often  met 
with  and  may  persist  in  spite  of  treatment  until  the 
varicocele  has  been  operated  upon.  Irritability  of  the 
vesical  neck,  vesical  hyperaesthesia  or  neuralgia — 
neuralgia  of  the  testes  and  cord,  a painful  sense  of 
dragging  and  weight  along  the  cord,  penile  or  ure- 
thral neuralgia,  pain  in  the  back  and  crural  neuralgia 
are  quite  constant  symptoms,  the  pain  in  the  back  be- 
ing usually  the  most  marked.  When  the  varicocele 
is  very  large,  the  scrotum  extremely  lax  and  pendul- 
ous and  its  veins  greatly  dilated  and  tortuous,  consid- 
erable mechanical  discomfort  may  be  experienced;  as 
one  of  my  patients  expressed  it,  the  tumor  “flopped 
against  his  legs  like  a cow’^s  bag.”  Should  the  sudo- 
riferous secretion  from  the  relaxed  scrotum  be  exces- 
sive, pruritus,  intertrigo  and  often  intractable  eczema 
ma}^  result.*  I have  a patient  at  the  present  time  who 
has  a most  obstinate  and  almost  intolerable  eczema 
due  to  a very  large  varicocele.  The  ordinary  reme- 
dies having  proven  ineffectual,  but  as  the  patient  has 


no  appetite  for  surgical  operations  my  S3^mpathies  are 
necessarily  reduced  to  a minimum.  The  cutaneous 
irritation  incidental  to  varicocele  was  long  ago  men- 
tioned by  Landouzy  as  an  indication  for  operation  as 
he  expressed  it,  “ the  continual  moisture  sometimes 
produces  a perfectly  unbearable  irritation  of  the  skin.” 
The  dermatitis  incidental  to  varicocele  is  obviouslj’ 
due  in  some  measure  to  friction  which  is  unavoidable. 

Wickham  calls  attention  to  violent  gastralgia  (?) 
chlorosis  and  marked  malnutrition  as  results  of  vari- 
cocele. 

In  recounting  the  symptoms  incidental  to  large  var- 
icoceles I do  not  wish  to  appear  dogmatic, as  the  pain 
and  other  uncomfortable  symptoms  are  not  necessari- 
ly proportionate  to  the  severit}^  of  the  disease.  In 
some  cases  of  slight  varicocele  the  patient  is  pro- 
foundly depressed  and  complains  greatly  of  reflex 
pains  in  the  back,  thighs  and  testes  wuth  associated 
marked  hypochondriasis.  In  other  cases  a large  vari- 
cocele may  produce  no  discomfort  whatever,  save 
that  which  is  incidental  to  its  size  and  the  consequent 
mechanical  inconvenience  ; consisting  chieflj'  in  im- 
peded locomotion.  Much  depends  on  the  sexual 
hygiene  of  the  patient.  If  this  be  normal,  his  symp- 
toms are  apt  to  be  comparative!)'  slight.  The  relief 
of  congestion  incidental  to  sexual  congress,  was  long 
ago  noted  as  beneficial  to  varicocele.*  Wickham, 
however  reports  a case  in  which  all  the  symptoms  were 
aggravated  for  some  days,  by  each  act  of  coition.t 

An  important  point  in  the  consideration  of  varico- 
cele is  the  danger  of  scrotal  hcematocele.  The  friable, 
degenerated  vessels  are  liable  to  rupture  under  falls, 
blows  or  strains.  One  case  of  hasmatocele  from  injury 
of  a varicocele,  has  come  under  my  own  observation. 
Vidal  reported  two  cases  of  this  kind.  That  the  dis- 
eased veins  may  rupture  spontaneously  has  been 
asserted,  but  I regard  this  accident  as  highly  improb- 
able, although  perhaps  not  impossible.  Escallier’s 


* Landouzy  op  cit. 
t These  de  Paris. 


cases  of  spontaneous  (?)  phlebitis  already  quoted  are 
important  in  this  connection. 

Atrophy  of  the  testicle,  already  alluded  to,  is  an 
inevitable  result  sooner  or  later,  in  severe  varicocele. 
This  is  an  important  consideration,  as  the  sound  tes- 
ticle may  become  diseased  independently  of  the  varix, 
and  lose  its  functional  power.  This  I regard  as  one 
of  the  prime  indications  for  surgical  interference  in 
large  varicoceles. 

That  varicocele  affects  the  structural  integrity  of 
the  testes  has  been  observed  by  such  writers  as  Curl- 
ing, Cooper,  Barwell,  Pott  and  Humphre}^  Numer- 
ous French  writers,  notably  Gosselin  and  Wickham, 
have  asserted  that  the  function  of  the  testicle  is  im- 
paired. One  of  Gosselin’s  observations  is  very  strik- 
ing. In  a case  of  marked  varicocele  on  the  left  side, 
the  patient  developed  an  epididymitis  in  the  opposite 
testicle.  Microscopical  examination  of  the  semen 
showed  the  complete  absence  of  spermatozoa.  This 
point  is  well  worthy  of  serious  consideration,  for 
under  certain  circumstances  an  operation,  producing 
as  it  does,  improvement  in  the  nutrition  and  function  of 
the  testes,  would  be  warranted  by  this  indication  alone. 

There  is  one  practical  point  which,  so  far  as  I know, 
has  not  been  noted  by  surgical  authorities  : I refer 

to  the  predisposition  to  hernia  existing  in  the  sub- 
jects of  varicocele.  I have  observed  several  cases 
in  which  hernia  followed  a slight  strain  in  adults 
who  had  long  been  affected  by  varicocele.  It  is 
admitted  that  the  same  constitutional  weakness  and 
local  structural  imperfection  that  predisposes  to  vari- 
cocele favors  the  occurrence  of  hernia,  but  it  has 
seemed  to  me  that  the  varicocele  per  se  had  a direct 
mechanical  influence  in  favoring  the  escape  of  the 
abdominal  contents.  The  continual  dragging  of  the 
varicocele  upon  the  structures  traversing  the  inguinal 
rings  and  canal  must  necessarily  enlarge  these  struct- 
ures and  thus  weaken  the  abdominal  walls  at  this  point. 
The  relaxed  condition  of  the  scrotal  tissues  is  also  a 
favoring  element  in  the  causation  of  hernia.  The 


148 

hernia  is  obviously  most  apt  to  occur  upon  the  side 
of  the  varicocele,  but  in  some  instances  the  opposite 
side  is  affected.  Here  the  causal  influence  of  the 
varix  per  se  is  not  easily  demonstrable,  but  scrotal 
relaxation  and  dragging  doubtless  have  some  effect. 

The  treatment  of  Varicocele  has  called  forth  the  in- 
genuity of  surgeons  in  many  ways  and  it  is  my  desire 
to  present  as  clearly  and  briefly  as  possible  the 
numerous  methods  that  have  been  suggested  by  vari- 
ous authorities. 

The  treatment  of  varicocele  in  its  milder  forms  is 
altogether  palliative — in  fact  in  a large  proportion  of 
cases  it  is  only  necessary  to  allay  the  patient’s  mental 
annoyance  by  a little  sound  physiological  advice. 
Instruction  in  sexual  physiology  and  hygiene  is  neces- 
sary in  all  cases  to  keep  the  patient  out  of  the 
clutches  of  the  quack  on  the  one  hand  and  to  assist 
in  a cure  on  the  other.  The  slighter  grades  of  varix 
will  be  found  to  disappear  on  the  removal  of  the  in- 
ducing conditions.  Such  cases  should  really  be 
termed  spermatic  congestion — they  disappear  on  re- 
moval of  constipation  and  regulation  of  the  sexual 
habits.  Marriage,  if  practicable,  is  the  best  remed3^ 
All  authorities  unite  upon  the  importance  of  attention 
to  the  bowels.  Should  the  patient  experience  a dread 
of  impotence,  some  pains  should  be  taken  to  correct 
his  morbid  impression,  else  the  prospect  of  matrimonx'’ 
is  apt  to  be  distasteful  to  him.  In  all  cases,  whether 
marked  or  slight,  due  attention  should  be  given  to 
measures  tending  to  restore  constitutional  tone.  Ex- 
ercise short  of  fatigue,  proper  hours  of  rest,  avoidance 
of  sexual  excess  and  the  use  of  the  shower  bath  are 
essential.  Regulation  of  the  diet  and  temperate 
habits  do  much  to  assist  in  a cure.  In  recommending 
exercise  the  patient  should  be  warned  against  violent 
strains  as  tending  to  increase  the  vari.x  and  favoring 
hernia  and  haematocele. 

If  varicocele  be  associated  with  frequent  pollutions 
or  spermatorrhoea,  it  may  be  necessarj"  to  adopt  some 
of  the  various  measures  of  treatment  for  these  condi- 
tions. If  there  be  hypochondriasis  or  neuralgic 


149 


symptoms  it  is  advisable  to  pass  a cold  sound  occas- 
ionally. The  results  of  this  simple  measure  are  often 
remarkable,  the  morale  of  the  patient  being  improved 
to  a wonderful  extent.  This  effect  is  due  primarily 
to  the  peculiarly  stimulating  effect  of  distension  of 
the  urethra,  upon  the  central  sympathetic  system  as 
well  as  to  a certain  moral  effect.  The  latter  effect  is 
usually  accorded  too  much  importance,  and  the  physi- 
ological effect  incidental  to  the  stimulation  by  stretch- 
ing of  such  regions  as  the  urethra,  cervix  uteri,  anus 
and  rectum  is  forgotten.  The  application  of  astring- 
ent ointments  or  suppositories  to  the  prostate  is  often 
of  great  benefit. 

In  the  correction  of  constipation,  mild  laxatives  and 
not  drastic  purgatives  should  be  given.  Remedies 
which  tend  to  relieve  hepatic  congestion  or  toiporare 
alwa3's  in  order.  Theoretical  considerations  aside, 
there  is  no  better  remed}^  than  minute  doses  of  calo- 
mel. The  tablet  triturates  of  Caswell.  Hazard,  & Co. 
in  doses  of  tV  to  gr.  at  bedtime  are  a favorite  with 
me.  One  who  has  never  used  them  will  be  convinced 
by  their  action  that  he  has  a great  deal  to  learn  re- 
garding the  use  of  this  much  abused  drug.  Of  the 
various  tonics,  non-constipating  preparations  of  iron, 
strychnia  and  the  mineral  acids  are  serviceable.  A 
very  satisfactorj^  tonic  is  the  new  preparation  of  “ the 
three  chlorides”  manufactured  by  Renz  & Henrj^  of 
Louisville.  I began  using  this  preparation  at  the 
suggestion  of  Dr.  J.  R.  Larrabee,  and  it  deserves  all 
that  he  says  cf  it. 

Remedies  which  are  supposed  to  act  directly  upon 
the  vascular  walls  have  been  highl}^  recommended  in 
varicocele.  Agnew  endorses  ergot  very  highl}^  As 
far  as  diseases  affecting  the  veins  are  concerned  I have 
more  faith  in  hamamelis  than  in  ergot,  but  neither  of 
these  drugs  is  apt  to  produce  much  benefit  in  varico- 
cele - this  is  readily  understood  on  dissection  of  the 
flabby  degenerated  mass  of  veins  composing  the 
varix. 

The  application  of  cold  to  the  part  is  a time-honored 
remedj'  in  varicocele;  douching  the  scrotum  with 


150 

cold  salt  water  is  an  excellent  adjuvant  to  other  meas- 
ures in  all  cases,  but  in  the  severe  forms  it  is  not  like- 
ly to  accomplish  much.  The  addition  of  astringent 
drugs  to  the  water  used  for  bathing  the  parts  is  en- 
dorsed by  high  authority.  Such  a measure  is  a little 
absurd  to  say  the  least.  Mechanical  measures  are 
sometimes  employed  for  the  purpose  of  exciting  con- 
traction of  the  dartos  muscle  in  the  hope  of  thereby 
impressing  the  varicocele.  Flagellation  for  fifteen  or 
twenty  minutes  with  a wet  towel  or  with  rubber  tub- 
ing has  been  recommended. 

Support  of  the  part  by  some  mechanical  device  is 
the  most  familiar  method  of  treatment  of  varicocele. 
A simple  but  troublesome  method  is  that  of  the  appli- 
cation of  adhesive  plaster  (Morgan’s  method).  The 
affected  side  is  encircled  with  strips  of  stout  plaster 
while  the  scrotum  is  elevated.  A loop  of  plaster  is 
now  applied  vertically  over  the  encircling  strips  and 
through  this  loop  a piece  of  bandage  is  passed,  its 
ends  being  attached  to  a waistband.  The  varicocele 
is  thus  elevated  and  theoretically  drained  of  blood. 
The  angle  produced  in  the  efferent  veins,  however, 
nullifies  the  possible  benefits  of  the  method. 

The  suspensory  bandage  is  an  every  da}^  method  of 
treatment,  but  after  all  it  is  on  the  average  carelessly 
selected  and  still  more  carelessly  used.  Most  of  the 
flimsy  devices  for  suspending  the  testes,  are  worse 
than  useless.  A suspensor}?  should  fit  accurately  and 
should  keep  the  parts  well  up.  The  surgeon  should 
not  leave  this  to  the  appliance  dealer,  but  should  at- 
tend to  it  himself.  A suspensory  should  be  light,  firm 
and  easily  adjusted.  Silk  and  rubber  tissue  are  too 
heating  and  not  ver}^  durable,  the}'  are  also  quite  ex- 
pensive if  well  made.  The  U.  S.  Army  suspensor}'- 
known  as  Rawson’s  is  superior  to  all  others  in  the 
market.  Morgan’s  suspensor}'  is  highly  endorsed. 
This  is  laced  in  front.  The  tumor  being  lifted  and 
drained  of  blood  is  placed  in  the  bag  and  the  laces 
carefully  adjusted.  A form  of  suspensory  has  been 
recommended  which  is  to  be  elevated  and  fastened  to 
a waistband  by  a strap  and  buckle  as  described  in  the 


I5I 

application  of  adhesive  strips.  To  this,  the  same  ob- 
jections may  be  urged  as  in  the  case  of  the  plaster. 

Infibulation  of  the  scrotum  has  been  recommended. 
The  best  appliance  for  this  purpose  is  the  soft  silver 
ring  devised  by  Wormald.  This  ring  is  covered  \vith 
soft  leather  or  rubber.  The  varicocele  is  emptied  of 
blood  and  the  scrotum  drawn  through  the  ring,  which 
is  then  compressed  to  a degree  just  sufficient  to  pre- 
vent the  veins  from  refilling.  The  principal  objection 
to  this  appliance  is  the  irritation  and  occasional  ulcer- 
ation of  the  scrotum  which  it  is  apt  to  induce.  Few 
patients  will  tolerate  it.  Curling  reports  a case  of 
Coulson’s  in  which  this  appliance  caused  sloughing 
of  the  scrotum.* 

Pressure  upon  the  spermatic  veins  at  the  external 
abdominal  ring  has  been  recommended,  the  object  be- 
ing “ to  direct  the  blood  back  into  other  and  smaller 
channels  than  the  spermatic  veins. t”  Various  trus- 
ses have  been  devised  for  this  purpose.  Stephen 
Smith  asserts  that  this  method  will  cure  severe  forms 
of  varicocele. J Gant  states  that  a truss  sometimes 
cures,  but  that  sometimes  the  veins  have  enlarged  as 
a consequence  of  the  method. § A truss  is  not  only 
difficult  to  adjust  with  the  proper  degree  of  pressure 
but  defeats  the  object  for  which  it  is  intended.  The 
pressure  enhances  the  already  existing  spermatic  con- 
gestion, never  completely  shuts  off  the  backflow  of 
venous  blood  and  affords  absolutely  no  support  to 
the  weakened  and  dilated  vascular  walls.  It  is  but 
just  to  state  however  that  Curling  and  later  Ravoth 
endorse  the  truss  treatment. 

Electricity  has  its  advocates  in  the  treatment  of 
varicocele.  Beyond  a certain  amount  of  circulatory 
stimulation  induced  by  the  faradic  current,  I consider 
electricity  absolutely  worthless.  Electrolysis  has 
been  suggested  but  I should  consider  it  not  only 


■’•'Diseases  of  Testis,  4th  Ed. 
f Agnew,  Surgery,  vol.  II.  p.  565. 
fOp.  of  Surg.  p.  273. 
gSurgery  p.  1081. 


152 


worthless  but  possibly  dangerous.  Further  experi- 
ence with  the  method  may  however  prove  its  value 
and  safety. 

Of  all  the  methods  of  treatment  which  have  been 
suggested,  that  by  hj'podermatic  injection  with  vari- 
ous chemicals  appears  to  me  to  be  the  most  painful, 
worthless,  illogical  and  dangerous.  I have  done  very 
little  experimenting  in  this  direction  and  I have  found 
that  either  the  patient  or  myself  was  very  glad  to  quit 
in  every  instance. 

Ergotine, * solution  of  persulphate  of  iron,  carbolic 
acidf  and  hydrate  of  chloral  have  each  had  their 
advocates  and  their  trains  of  disgruntled  patients. 
Even  poor  old  alcohol  has  been  appealed  to  for  a 
cure,  a Russian  with  the  euphonious  cognomen  of 
Duhonovsky  being  the  guilty  party.  | 

The  possible  dangers  of  the  injection  method  are 
obvious:  Cellulitis, sloughing, orchitis,  tetanus,  phle- 

bitis and  septic  infection  are  all  within  the  range  of 
possibilities. 

Bonnet,  Philippeaux  and  Rigaud  used  Vienna  paste 
and  chloride  of  zinc  to  the  scrotum  to  produce  a radi- 
cal cure,  and  obtained  some  good  results. 

It  is  not  necessary  to  comment  upon  this  method 
of  aforetime. 

The  various  palliative  measures  which  have  been 
suggested  are  usually  sufficient  to  relieve  the  symp- 
toms and  prevent  an  increase  in  the  size  of  the  varix 
in  cases  of  moderate  severity.  In  the  more  severe 
cases,  however,  the  characteristic  changes  in  the  vas- 
cular walls,  due  mainly  to  a loss  of  tone  and  connec- 
tive tissue  proliferation,  go  on  and  we  have  an  in- 
crease in  size  of  the  varix  with  consequent  aggrava- 
tion of  the  symptoms.  In  the  more  marked  cases 
the  physical  deformity  is  apt  to  be  considerable  and 
may  occasion  great  anno}’ance.  Some  men,  however, 
are  not  hypersensitive,  judging  by  the  exhibitions 
which  one  may  often  observe  on  the  street  cars. 


*Bartarelli  and  Citaglia.  Ashhurst  1077. 
ILeonard  Weber, 
j;Ashhurst.  1077. 


153 


During  the  seasons  wiien  tight  pantaloons  are  in 
fashion,  Comstock  should  be  kept  busy.  In  large 
varicoceles  the  suspensory  bandage  fails  to  prevent 
noticeable  deformity  and  the  consequent  failure  to  re- 
lieve the  mental  S3'mptoms  is  especially  pronounced. 
In  adjusting  his  bandage  the  owner  of  a varicocele  is 
made  painfully  cognizant  of  his  deformity.  The 
knowledge  that  he  is  unlike  other  young  men  as  re- 
gards his  sexual  apparatus  is  apt  to  have  a peculiarly 
demoralizing  effect.  The  various  symptoms  of  a sub 
jective  character  that  have  alread}^  been  enumerated 
demand  relief  of  a more  substantial  character  than 
palliative  measures  afford.  If  impotency  exist,  the 
matter  is  of  urgent  importance,  especially  where  per- 
petuation of  famil}’  is  of  moment. 

I do  not  wish  to  be  recorded  as  advising  indiscrim- 
inate operation  in  varicocele,  but  I do  claim  that  a cer- 
tain proportion  of  cases  demand  operation.  I think 
moreover,  that  this  proportion  is  larger  than  is  usuall}' 
believed.  The  dogma  of  infallibilit}^ which  surrounds 
the  teachings  of  the  surgical  authorities  of  the  past 
with  a halo  of  intolerance,  has  so  far  infected  the  prac- 
tice of  the  modern  surgeon  that  he  usually  discounten- 
ances any  and  all  operative  measures  in  varicocele — 
which  in  his  eyes  at  least  is  a surgical  noli  me  tangere. 
Van  Buren  was  strongly  opposed  to  all  operative  meth- 
ods in  varicocele,  and  his  teachings  have  done  much 
to  prevent  surgical  interference  in  these  cases.  ( It  is  a 
common  experience  for  the  surgeon  who  is  willing  to 
operate  in  suitable  cases,  to  be  criticised  by  the  ma- 
jorit}'  of  his  brethren  to  whose  attention  the  particu- 
lar case  chances  to  be  brought.  Most  of  the  criti- 
cism comes  from  men  who  not  only  have  never  per- 
formed an  operation  for  varicocele,  but  probable  have 
never  seen  one  performed.  As  conservative  a sur- 
geon as  Segond,  who  claimied  that  in  the  majority  of 
cases  operation  was  unnecessar}’,  said  that  “operation 
is  certainly  pardonable  when  the  inconveniences  of 
the  condition  are  greater  than  the  dangers  of  inter- 
vention. ’ ’ 

Having  acknowledged  that  the  majority  of  cases  of 


154 


varicocele  may  be  satisfactorily  temporized  with,  it  is 
certainly  not  overbold  for  one  to  advocate  operative 
measures  in  some  of  the  severe  cases  that  come  under 
our  care,  the  more  especially  as  operation  nearly  al- 
ways relieves  the  pain  which  so  frequently  exists.  If 
moreover,  a method  of  operating  be  practicable  that 
is  perfectly  safe,  there  can  be  no  objection  to  opera- 
tion even  in  cases  of  moderate  severity.  As  Wickham 
remarks,  “the  facts  prove  that  large  varicoceles  may 
lead  to  serious  consequences,  such  as  haematocele 
and  phlebitis,  spontaneous  or  traumatic.’’  This  point 
is  worthy  of  attention  in  considering  the  justification 
of  an  operation. 

The  indications  for  operation  in  varicocele  may  be 
formulated  as  follows : 

].  When  the  varicocele  is  very  voluminous  and  a 
cause  of  marked  deformity. 

2.  When  the  varicocele  is  very  painful,  or  is  the 
cause  of  reflex  neuralgia  of  a severe  tj  pe. 

3.  When  aberration  of  the  sexual  function  exists. 

4.  When  irritation  of  the  scrotum  is  marked  and 
obstinate. 

5.  When  the  varicocele  interferes  with  the  occupa- 
tion. 

6.  When  the  affected  testicle  is  atrophy’ing. 

When  the  opposite  testis  is  diseased. 

8.  When  symptoms  of  mental  aberration  are  pro- 
nounced. 

9.  When  the  varix  is  an  obstacle  to  entering  pub- 
lic service — militarjq  naval  or  civil. 

An  operation  having  been  decided  upon  it  remains 
for  us  to  select  the  method.  Before  advocating  any 
particular  operation  I will  endeavor  to  present  briefly' 
and  fairly  the  principal  operations  which  have  been 
recommended.  The  operations  by'  castration,  resec- 
tion of  the  vas  deferens  and  ligature  of  the  spermatic 
arteries  are  unworthy'  of  notice. 

One  of  the  earliest  operations  was  that  of  Vidal  de 
Cassis.*  This  method  consists  in  passing  an  iron  pin 


*De  lacure  radicale  du  varicocele  parl’enroulement,  etc.,  1850. 


155 


through  the  scrotum  between  the  vas  deferens  and 
the  enlarged  veins.  A silver  wire  is  then  passed 
along  the  pin  outside  the  veins  which  are  thus  in- 
cluded between  the  pin  and  the  wire.  The  wire  is 
now  fastened  to  the  ends  of  the  pin  and  the  latter 
twisted  so  as  to  bring  a certain  amount  of  pressure  to 
bear  upon  the  vessels  {enroiilement).  The  twisting 
process  is  repeated  every  day  or  two  until  the  veins 
ulcerate  through  and  the  pin  becomes  loose ; pin  and 
wire  are  then  withdrawn.  The  veins  are  thus  cut 
across  and  obliterated  by  inflammatory  adhesions. 
This  is  the  principle  involved  in  all  methods  of  de- 
ligation in  varicocele.  Bradley  modifies  Vidal’s  opera- 
tion by  using  a second  pin  instead  of  a wire,  thus  ob- 
literating the  veins  by  acupressure.  Markoe  modi- 
fies it  by  dispensing  with  the  pin  and  using  a loop  of 
silver  wire  clamped  to  a lead  plate.  The  wire  is 
gradually  tightened. 

Ricord’s  method  is  practically  the  parent  of  the 
methods  of  subcutaneous  deligation.  Two  double 
ligatures  introduced  through  a single  opening  through 
the  scrotum.  One  double  ligature  passes  above  the 
veins  (between  the  veins  and  the  vas  deferens)  and  the 
other  below  them.  The  loop  of  one  ligature  and  the 
two  ends  of  the  other  project  at  each  opening.  The 
free  ends  are  now  threaded  through  the  corresponding 
loops  and  made  fast  to  a small  yoke  provided  with  a 
screw.  This  is  tightened  from  day  to  day  and  the 
loops  thus  drawn  into  the  scrotum  so  as  to  eventually 
strangulate  and  cut  through  the  enlarged  veins.  The 
ligatures  come  awa}^  in  the  second  or  third  week. 

Wood’s  modification  of  the  Kicord  operation  con- 
sists in  the  application  of  a single  subcutaneous  liga- 
ture of  annealed  iron  wire.  The  ends  of  the  loop  are 
fastened  to  a light  steel  spring,  the  constant  tension 
of  which  cuts  off  the  veins.  Apiece  of  adhesive  plas- 
ter should  be  placed  under  the  spring  to  prevent  its 
cutting  into  the  scrotum,  .and  over  all  an  antiseptic 
wool  dressing  may  be  applied.  (DeWitt-Boyd.) 

Davat’s  operation:  This  method  is  strongly  en- 

dorsed by  Agnew,  who  claims  that  he  has  seen  no  bad 


156 

results  from  it  in  twenty  years’ experience.*  Accord- 
ing to  this  author  none  of  the  many  imitations  of 
Davat’s  operation  are  simpler  or  more  permanent  in 
results. 

The  hair  is  first  removed  from  the  scrotum.  The 
cord  is  next  grasped  between  the  thumb  and  index 
and  middle  fingers  about  one  inch  below  the  external 
abdominal  ring,  and  rolled  about  until  the  vas  de- 
ferens has  been  isolated  and  slipped  behind  the^  re- 
maining constituents  of  the  cord.  A stout  acupres- 
sure needle  is  now  thrust  between  the  duct  and  the 
veins  and  along  it  is  passed  a needle  armed  with  a 
stout,  well  waxed  hempen  ligature.  This  traverses 
the  scrotum  in  front  of  the  veins  and  passes  out  of 
the  distal  needle  puncture.  The  loop  of  the  ligature 
is  now  slipped  over  one  end  of  the  pin  and  its  free 
ends  tied  over  the  other.  The  entire  ligature  now 
slips  within  the  integument  and  becomes  subcutan- 
eous. A cork  is  now  placed  upon  the  sharp  end  of 
the  pin,  and  the  scrotum  kept  elevated  on  a small 
cushion.  The  pin  should  be  removed  on  the  seventh 
day.  In  this  method  it  is  not  necessary  to  wait  until 
the  veins  are  cut  through  before  removing  the  pin. 
A suspensory  bandage  should  be  worn  for  two  or  three 
weeks. 

Bryant’s  method  is  as  follow's:  The  vas  deferens 

is  pushed  aside  and  a stout  needle  armed  with  a liga- 
ture is  passed  through  the  scrotum  beneath  the  veins. 
A needle  set  in  a handle  is  next  passed  through  the 
same  opening  and  made  to  traverse  the  scrotum  in 
front  of  the  veins,  emerging  at  the  point  of  exit  of 
the  first  needle.  The  distal  end  of  the  ligature  is 
now  threaded  to  the  eye  of  the  second  needle  and 
drawn  back  out  of  the  wound  of  entr}”,  the  loop  is 
thus  made  to  include  the  dilated  veins.  The  skin  at 
the  entrance  and  exit  is  now  divided  with  a tenotome 
and  the  ligature  tied  tightly,  its  loop  becoming  sub- 
cutaneous. A second  ligature  is  now  applied  above 
or  below  the  first  in  a similar  manner.  The  included 
area  of  veins  ma}'  be  divided  subcutaneousl}'  if 


ttgnew,  Surgery.  Tol.  II.  P-  566. 


157 


required.  Of  late  years  Bryant  has  not  divided  the 
veins.  Great  success  and  safety  is  claimed  for.this 
operation. 

Erichsen’s  method:  Erichsen  makes  an  incision 

about  half  an  inch  in  length  in  front  and  behind  the 
scrotum.  A needle  armed  with  a silver  wire  is  now 
passed  into  the  anterior  incision,  between  the  vas  de- 
ferens and  veins  and  out  of  the  posterior  opening. 
The  needle  is  now  returned  in  front  of  the  veins  so 
that  they  are  included  in  the  loop  of  wire.  The  ends 
of  the  loop  are  now  twisted  so  as  to  constrict  the 
veins;  the  twisting  is  repeated  daily  until  the  veins 
are  cut  through  and  obliterated 

Gould’s  method  is  rather  novel:  This  operation  is 

as  follows:  The  vas  deferens  and  veins  are  separated 

high  up;  the  skin  is  now  pinched  up  and  transfixed 
by  a small  narrow  bladed  bistoury  or  tenotome  and  a 
small  opening  thus  made.  A needle  armed  with 
stout  platinum  wire  is  now  passed  under  the  veins 
which  are  lifted  out  of  the  opening.  The  wire  is  now 
fastened  to  the  ecraseur  handle  of  a cautery  battery. 
The  wire  is  heated  to  a cherry  red  heat  and  speedil}^ 
cuts  through  and  at  the  same  time  seals  the  veins. 
Great  caution  is  necessary  to  avoid  cutting  the  veins 
too  rapidly  and  thus  causing  haemorrhage.  Gould 
reports  twenty-five  successful  cases.  The  same  meas- 
ures of  rest,  antisepsis  and  support  of  the  part  are 
necessary  as  in  other  operations.  The  obliteration 
of  the  affected  veins  by  the  galvano-cautery,  was  first 
suggested  by  Dubreuil,  a French  surgeon 

Gross’  operation:  This  consists  of  subcutaneous 

ligature  with  a stout  cord  or  silver  wire.  This  is 
passed  by  means  of  a long  spear-shaped  needle.  Pan- 
coast fastens  the  ends  of  the  ligature  to  a broad  but- 
ton, while  Gross  in  the  original  method  used  a com- 
press of  cork.  The.  ligature  is  tightened  or  in  the 
case  of  wire,  twisted  every  daj^  until  free. 

The  late  Dr.  Levis  advised  tying  the  ligature  over 
a section  of  stout  rubber  tubing  to  obviate  the  neces- 
sity of  tightening  from  day  to  day.  The  elasticity  of 
the  tubing  affords  the  necessary  traction. 


15^ 

Holmes’  method  : This  involves  cutting  down  up- 

on the  venous  plexus  by  a very  small  incision  and 
tying  the  veins  with  kangaroo  tendon.  The  wound 
is  then  made  practically  subcutaneous  by  antiseptic 
dressings.  The  tendon  is  eventually  absorbed. 

Keye’s  method  : This  is  one  of  the  best  of  the  sub- 

cutaneous operations.  The  scrotum  is  shaved  and 
scrubbed  first  with  soap  and  water  and  then  with 
bichloride  solution.  A few  drops  of  a 4 per  cent  co- 
caine solution  are  now  injected  at  point  of  proposed 
puncture.  Anaesthesia  is  not  advisable  as  the  opera- 
tion is  best  performed  in  the  standing  position.  : A 
specially  devised  needle  is  now  passed  between  the 
veins  and  the  vas  deferens  high  up.  This  is  armed 
with  an  aseptic  silk  ligature.  As  soon  as  the  needle 
emerges  posteriorly  the  loop  of  silk  is  seized  and 
secured  and  the  needle  withdrawn  far  enough  to  al- 
low the  veins  and  vas  to  come  together,  after  which 
it  is  passed  in  front  of  the  veins  and  out  of  the  pos- 
terior opening.  The  second  loop  is  now  secured  and 
the  needle  withdrawn.  The  free  ends  of  the  loop  are 
now  tied  tightly  and  allowed  to  sink  into  the  scrotum. 
An  antiseptic  dressing  is  applied  and  the  patient  put 
to  bed.  Keyes  claims  that  ten  da}^s  is  the  longest 
period  of  confinement  to  bed.  One  patient  he  claims 
was  about  in  48  hours.  Weir  advocates  the  Ke\’es 
method. 

Alexander  Ogston,  of  Aberdeen,  advocates  subcu- 
taneous ligation  with  silk,  the  operation  being  practi- 
cally the  same  as  that  of  Kej’es. 

Henry  Lee  has  practiced  several  different  opera- 
tions. His  acupressure  method  is  as  follows  : The 

veins  are  separated  from  the  vas  deferens  and  two 
pairs  of  stout  straight  needles  passed  through  the 
scrotum,  one  needle  of  each  pair  passing  between  the 
veins  and  the  vas  deferens  and  the  other  outside  the 
veins,  which  are  compressed  between  the  two.  The 
veins  are  thus  acupressed  at  two  points.  The  two 
pairs  of  needles  should  be  about  one  inch  apart.  The 
ends  of  each  pair  are  fastened  together  by  elastic 
bands,  thus  insuring  continuous  compression.  The 


159 

veins  are  now  divided  subcutaneously  with  a teno- 
tome. 

Should  bleeding  follow  a third  pair  of  needles 
should  be  introduced — below,  if  the  bleeding  be  ven- 
ous; above,  if  it  be  arterial  Lee’s  open  operation 
consists  in  the  excision  of  a section  of  the  scrotum, 
the  application  of  ligatures  a short  distance  apait,and 
excision  of  the  included  area  of  veins.  Of  late,  Lee 
has  applied  temporary  compression;  excised  the  de- 
sired area  of  veins  and  finished  by  sealing  the  cut 
ends  of  the  vessels  with  the  cautery.  Antiseptic  dres- 
sings are  of  course  essential  to  success.  Ashhursthas 
modified  Lee’s  first  method  by  passing  harelip  pins 
and  loops  of  silver  wire  subcutaneously.  The  elastic 
bands  are  substituted  by  silk  ligatures  which  are  re- 
moved the  next  dajc 

A.  E.  Barker’s  method  (so  called)  xonsists  in  the 
application  of  subcutaneous  antiseptic  silk  ligatures 
at  one  or  two  points. 

Barwell’ s method  consists  in  the  subcutaneous  appli- 
cation of  a silver  wire  in  the  usual  fashion.  The  loop 
may  be  drawn  into  the  scrotum  or  left  outside,  in 
either  event  the  free  ends  are  twisted  from  day  to  day 
until  the  wires  are  free,  when  they  are  removed. 

Annandale’s  method  is  essentially  that  of  Lee,  with 
the  exception  that  the  veins  only  are  excised,  the 
scrotum  being  left  intact.  Howse  and  Banks  endorse 
this  operation. 

Bogue’s  method  consists  in  exposing  the  veins  and 
applying  catgut  ligatures  at  various  points. 

Curling’s  method  is  essentially  that  of  Davat,  it 
differs  only  in  the  use  of  two  pins  and  the  division  of 
the  veins  between  the  pins  with  a f_ne  thin-bladed 
tenotome. 

Howse’s  method  is  as  follows:  The  parts  having 

been  shaved  and  rendered  aseptic,  an  incision  1^  to 
2 inches  long  is  made  over  the  varicocele  beginning 
inch  below  the  external  ring.  The  veins  are  ex- 
posed with  as  little  disturbance  of  surrounding  parts 
as  possible.  An  aneurism  needle  armed  with  chromic 
gut  is  now  passed  at  each  angle  of  the  wound,  the 


i6o 

ligatures  tied  and  the  included  section  of  veins  ex- 
cised with  a pair  of  blunt  scissors.  A horse-hair 
drain,  horse-hair  sutures,  iodoform  and  antiseptic 
gauze  dressings  complete  the  operation.  The  horse- 
hair drain  is  removed  on  the  fourth,  and  the  sutures 
on  the  eighth  day.  Redundant  scrotum  may  be  ex- 
cised or  enlarged  scrotal  veins  tied  in  this  operation 
it  required.  As  an  illustration  of  the  variance  of  opin- 
ion regarding  this  method,  Jacobson  terms  it  the 
safest  and  best  of  all  methods  and  asserts  its  freedom 
from  danger,*  while  Holmes  says  that  it  is  a severe 
operation  which  has  been  followed  by  dangerous 
haemorrhage,  gangrene  of  the  testis  and  severe  and  ex- 
tensive suppuration. J 

Kocher  ties  the  veins  at  two  points  and  divides  the 
veins  subcutaneousl}'.  Briggs,  of  Nashville,  prac- 
tices a similar  method. 

Treve’s  operation  consists  in  an  incision  one  inch 
in  length,  exposure  of  the  veins,  the  application  of 
two  ligatures  and  the  excision  of  the  enclosed  area  of 
veins.  A drainage  tube  of  small  caliber,  and  antisep- 
tic dressings  complete  the  operation.  This  is  another 
operation  illustrating  the  amount  of  originality  neces- 
sary to  immortalize  an  operator. 

Weir’s  method  is  not  claimed  by  him  to  be  the  acme 
of  originality.  In  this  respect  Weir  differs  from  the 
majority  of  operators.  Weir  states  that  Gagneles 
was  the  first  to  practice  ligation,  silk  being  the  mate- 
rial used.  He  also  refers  to  Washburne’s  and  Fuf- 
nell’s  suggestions  of  the  use  of  a third  wire  in  W ood’s 
operation.  Weir  prefers  the  subcutaneous  applica- 
tion of  carbolized  or  juniperized  catgut,  22  cases  are 
reported,  of  which  only  six  were  unsatisfactort'.  The 
average  confinement  to  bed  was  eight  da}^s.  Accord- 
ing to  Weir,  excision  of  the  veins  was  first  practiced 
by  Patruban  in  18*70,  and  revived  by  Nebler  in  1880. 
Following  these  the  operation  was  practiced  by  Ni- 
caise,  Zesas,  Lee  and  others. 


*W.  H.  A.  Jacobson— Operations  of  Surger.r. 
tT.  Holmes— Surger.v. 


i6i 


Reginald  Harrison  ligates  the  large  vessels  separ- 
ately and  cauterizes  the  smaller  ones. 

Abbe,  of  N.  Y.  has  practiced  resection  of  the  scro- 
tum with  the  application  of  several  ligatures  at  vari- 
ous points  in  the  exposed  veins.  He  reports  six  cases 
with  excellent  results. 

Fig.  1. 


Case  of  extreme  elongation  of  scrotum  before  operation. 

(After  Horteloup.) 

Sir  Astley  Cooper’s  operation  is  the  parent  of  all 
operations  involving  excision  of  the  redundant  scro- 
tum. In  this  operation  a portion  of  the  redundant 
tissue  is  grasped  between  the  fingers  and  excised  with 
knife  or  scissors.  Haemorrhage  having  been  checked 
the  edges  are  stitched  with  interrupted  sutures  and — 


* M^moire  a I'Academie  inedit. 


i62 


nowadays — antiseptic  dressings  applied.  Van  Bu- 
■:en  characterized  this  operation  as  the  only  justifiable 
procedure  in  the  vast  majority  of  cases  of  varicocele. 

Horteloup’s  modification  of  the  Cooper  operation 
involves  resection  of  the  redundant  scrotum  with  re- 
section of  a portion  of  the  veins  behind.  This  opera- 
tion is  practiced  by  De  Wenter  and  Theophile  Anger. 
Horteloup  uses  a specially  devised  clamp. 

Fig.  2. 


Case  of  extreme  elongation  of  scrotum  after  operation. 

(After  Horteloup.) 

Andrews  of  Chicago  is  the  originator  of  a clamp  (or 
retentive  compressor)  for  excision  designed  to  obviate 
injurious  pressure  on  the  tissues  during  the  opera- 
tion. 

Hutchinson  practices  the  open  method  of  deliga- 
tion, Rigaud  and  Senn  advocate  the  ligature,  the 
latter  tying  at  two  points;  neither  of  these  operators 
excises  the  veins. 

M.  Lucas  Champonnidre  and  Le  Dentu  both  prac- 
tice scrotal  resection,  the  former,  however,  using  no 


163 

clamp.  Le  Dentu  excises  the  retro-deferential  plexus. 

Henry’s  operation  is  in  my  opinion  the  best  of  the 
single  operations  in  selected  cases.  I was  formerl}' 
inclined  to  endorse  all  that  Henry  claims  for  it,  but 
I have  latterly  modified  my  opinion  and  consequently 
my  practice,  as  will  shortly  appear. 

Henry’s  method  is  a systematic  modification  of  the 
old-time  procedure  of  Astley  Cooper  with  the  addi- 
tion of  modern  aseptic  and  antiseptic  precautions  and 
dressing.  The  operation  is  performed  with  the  aid 
of  a specially  devised  clamp,  and  with  a little  expe- 
rience is  rapid  and  as  simple  as  may  be. 

■The  scrotum,  pubes  and  thighs  should  be  shaved 
and  well  scrubbed  with  soap  and  water,  followed 
after  drying  with  solution  of  the  bichloride.  The 
clamp  is  then  applied  from  above  downward,  care  be- 
ing taken  to  depress  it  well  down  toward  the  perineum 
and  to  have  the  raphd  of  the  scrotum  exactly  in  the 
center  of  the  condemned  portion  of  tissue.  The 
scrotum  is  drawn  through  the  blades  of  the  clamp 
until  the  testes  are  drawn  up  tightly  against  the 
pubes,  and  the  screw  tightened  so  that  the  clamp 
firmly  grasps  the  skin.  Carbolized  silk  or  catgut 
sutures  are  now  inserted  less  than  one-half  inch  apart, 
or  a number  of  harelip  pins  passed  through  the  scro- 
tum just  above  the  main  blade  of  the  clamp,  about 
three-fourths  of  an  inch  apart,  with  intervening  su- 
tures. The  sutures  or  pins  having  been  adjusted, 
the  redundant  tissue  is  cut  away  with  scissors 
or  knife.  The  secondary  or  removable  blade  of  the 
clamp  is  now  removed  and  the  sutures  loosely  tied. 
The  entire  clamp  is  now  removed  and  as  soon  as  all 
haemorrhage  has  ceased  the  sutures  are  permanently 
tied  and  antiseptic  dressings  applied.  There  are  some 
details  which  I consider  all  important  that  will  be 
mentioned  later  on.  There  is  one  point  upon  which 
Henry  insists,  in  which  I endorse  him  most  heartily, 
viz. : “there  is  more  danger  of  taking  away  too  little 
than  too  much  scrotum.”  I will  add  that  in  my  opin- 
ion it  is  well  nigh  impossible  to  get  away  too  much 
tissue  where  the  clamp  is  used.  An  important  feature 


164 

of  the  structure  of  this  region  is  the  readiness  with 
ivriich  the  integumentary  tissues  of  the  inner  aspect 
of  the  thighs  may  be  drawn  over,  thus  assisting  in 
icrming  a covering  for  the  testes.  The  operation  of 
resection  in  suitable  cases  is  followed  by  relief  of  pain, 
and  an  improvement  in  the  consistency  and  volume 
cA  the  affected  testis.  Wickham  claims  that  he  has 

Fig.  3. 


Varicocele  7 years  after  resection  of  scrotum. 

reiiivedpain  by  resection  after  Vidal’s  method  had 
failed. 

Wickham,  of  Paris,  uses  Horteloup’s  modification 
of  Henry’s  clamp  which  is  intended  to  accurately  in- 
dicate the  proper  line  of  incision.  This  clamp  has  a 
seiriicircular  form  in  the  middle  of  the  blades.  I do 
p.o:  like  this  device  as  well  as  that  of  Henry.  Henry’s 


i65 

operation  may  be  modified  b}^  the  use  of  the  quilled 
or  shotted  suture  if  the  operator  so  chooses. 

As  an  illustration  of  the  extreme  degree  of  elonga- 
tion of  the  pendulous  scrotum  and  the  large  amount 
of  tissue  requiring  removal  in  some  instances,!  append 
cuts  of  one  of  Honeloup’s  cases  before  and  after  the 
operation  of  resection.  (Figs.  1 & 2.)  There  is  one  fact 
which  to  me  appears  very  plain  from  these  illustrations, 
and  that  is  that  insufficient  tissue  was  removed.  I should 
be  greatly  pleased  to  know  the  condition  of  this  pa- 
tient some  years  after  operation,  for  in  cases  with  such 
extreme  elongation  of  the  scrotum  there  is  a marked 
tendency  to  recurrence,  if  resection  alone  be  depended 
upon.  In  my  own  cases  of  recurrence  the  testes 
after  operation  were  drawn  up  very  snugly  and  the 
scrotum  did  not  approximate  so  nearly  the  contour  of 
the  normal  scrotum  as  is  seen  in  the  appended  illus- 
tration of  Horteloup’s  case  after  operation. 

I greatly  regret  my  inability  to  present  illustrations 
of  several  of  my  cases  of  resection  of  the  scrotum 
showing  their  condition  some  years  after  operation. 
It  might  be  urged  that  I did  not  remove  sufficient 
scrotum  as  an  explanation  of  the  recurrence  in  my  cases. 
I have  elsewhere  expressed  myself  upon  this  point.  I 
have  the  good  fortune  to  possess  a photograph  of  a 
case  in  which  a surgeon  of  national  reputation  per- 
formed scrotal  resection  seven  years  ago.  This  sur- 
geon reported  this  case  as  radically  cured.  The  cut 
herewith  appended  casts  an  element  of  doubt  upon  the 
claims  of  the  operator — a doubt  which  approximates 
conviction  in  the  mind  of  the  patient. 

In  discussing  the  merits  of  the  various  operative 
procedures  for  varicocele  it  is  not  necessary  to  take 
them  up  in  detail;  the  raison  d'etre  of  many  of  the 
specially  devised  (?)  and  named  operations  is  ap- 
parent only  to  the  operator.  The  indication  in  all 
operations  is  to  limit  or  suppress  the  circulation  in 
the  plexus  composing  the  varix.  For  our  purpose, 
the  various  methods  may  be  divided  into  i.  Acu- 
pressure ; ? 3,  Subcutaneous  deligation  ; 3,  Open 

deligation;  4,  Deligation  with  resection  of  veins;  5, 


Deligation  with  resection  of  scrotum;  6,  Resection 
of  the  scrotum. 

1.  The  employment  of  acupressure  at  the  pres- 
ent day  is  an  evidence  of  a lack  of  faith  in  modern 
antisepsis,  and  to  my  mind  is  much  like  the  Dutch- 
man’s method  of  cutting  off  his  dog’s  tail,  “ an  inch 
at  a time  so  that  it  wouldn’t  hurt  him  so  much.” 
Gradual  obliteration  of  the  veins  by  pressure — with  or 
without  ulceration — has  all  the  dangers  of  immediate 
deligation  as  far  as  sepsis  and  trauma  are  concerned, 
and  moreover  these  dangers  are  continuous!}'  in- 
curred from  start  to  finish,  whether  the  process  re- 
quires a few  days  or  several  weeks.  I include  under 
the  term  acupressure  all  the  methods  involving  grad- 
ual obliteration  of  the  veins.  The  dangers  of 
acupressure  are  in  a measure  similar  to  those  of  sub- 
cutaneous deligation,  shortly  to  be  described. 

2.  Subcutaneous  deligation  is  not  an  essentially 
dangerous  operation  in  skillful  hands.  Unfortun- 
ately, however,  the  rank  and  file  of  operators  are 
not  as  skillful  as  some  of  those  who  claim  such  ex- 
traordinary success  with  this  method.  Simple  as  the 
various  methods  of  subtaneous  ligation  may  appear, 
serious  accidents  have  occurred.  The  operation  is 
done  in  the  dark,  so  to  speak,  and  more  tissue  is  in- 
cluded than  is  essential  to  the  cure  of  the  varix.  A 
certain  amount  of  cellular  tissue  is  certain  to  be  in- 
cluded with  the  mass  of  veins,  and  the  strangulation 
of  this  tissue  is  not  conducive  to  safety.  The  veins 
also  may  not  be  completely  strangulated.  The  fol- 
lowing case  by  McKay  illustrates  this  point; 

“ In  the  early  summer  of  1888  I was  called  in  by 
Dr.  Habib  Tubagy  of  Beyrout,  Syria,  to  operate  on 
Mr.  Nasif,  an  unmarried  carpenter  of  that  city.  Two 
days  previous  to  this  he  had  been  operated  on  by 
Vidal’s  method,  but  as  there  w’as  considerable  swell- 
ing of  the  scrotum,  and  he  was  suffering  much  pain, 
he  desired  the  radical  operation  by  the  open  method. 
After  thoroughly  cleansing  the  parts,  an  incision  was 
made  similar  to,  but  somewhat  shorter  than,  that  in 
the  former  case.  The  wires  were  found  enclosing  the 


i67 


blood-vessels  and  much  cellular  tissue,  and  not  tight 
enough  to  entirely  arrest  the  flow  ol  blood.” 

A portion  of  scrotal  tissue  may  be  included  in  the 
loop  of  ligature  unless  great  care  be  taken.  The 
veins  being  squeezed  up  en  masse,  there  is  less  securi- 
ty against  secondary  hemorrhage  than  when  they  are 
ligated  separately.  Scrotal  haematocele,  phlebitis, 
septic  infection,  thrombosis  and  embolism  are  possi- 
bilities. Regarding  the  latter,  however,  it  is  my 
opinion  that  there  is  more  danger  of  thrombosis  and 
embolism  in  gradual  occlusion  of  the  veins  than  in 
their  cleanly  individual  deligation. 

Subcutaneous  deligation,  while  not  so  dangerous 
in  this  respect  as  acupressure  and  its  congeners,  is 
more  so  than  a neat  open  operation.  Strict  asepsis 
neutralizes  all  possible  claims  for  the  timid  and  hap- 
hazard deligation  in  the  dark.  Surgeons  of  some  ex- 
perience have  included  the  vas  deferens  in  the  loop 
of  ligature  or  wire  with  resultant  atrophy  of  the  tes- 
tis. A case  of  this  kind  has  occurred  in  Chicago. 
Atrophy  of  the  testis,  however,  does  not  necessarily 
imply  inclusion  of  the  vas  deferens,  as  ligation  of  the 
spermatic  veins  alone  has  produced  it.  I believe 
though  that  the  danger  of  atrophy  has  been  overrated. 
Severe  varicocele  is  attended  by  atrophy  of  the  tes- 
tis ; sonretimes  to  a marked  degree;  as  the  varicocele 
subsides  this  degenerate  condition  becomes  apparent. 
Tetanus  is  one  of  the  possible  results  of  inclusion  of 
the  vas  deferens. 

Richet,  in  practicing  the  method  of  enroiilement,  has 
observed  that  a vein  with  hardened  and  thickened 
walls  is  occasionally  found  in  the  midst  of  the  mass 
composing  the  varicocele,  which  may  be  mistaken  for 
the  vas  deferens.  He  relates  a case  in  which  both 
he  and  Denonvilliers  were  in  doubt  in  the  perform- 
ance of  Vidal’s  operation.  Richelot  cites  a similar 
case. 

Many  surgeons  believe  that  the  chief  danger  of 
ligation  subcutaneously  is  inclusion  of  the  spermatic 
artery,  which  is  deeply  situated  amid  the  mass  of  veins 
composing  the  varix.  Ligation  of  this  artery,  it  is 


i68 


claimed,  leads  to  certain  atrophy  of  the  testis.  This 
is  the  opinion  of  Gosselin,  and  following  him,  Levis, 
Gouley,  Jenks,  Malgaigne  and  Henr}n  Nicaise  is  also 
very  chary  of  tying  the  artery.  Malgaigne  holds  that 
it  is  impossible  to  avoid  die  artery  and  that  therefore, 
subcutaneous  deligation  is  equivalent  to  castration. 
Guyon  and  Richelot  claim  that  the  arteries  of  the 
vas  deferens  and  cord  proper,  are  sufficient  to  preserve 
the  nutrition  of  the  testicle. 

W.  H.  Bennett  remarks  on  this  point  as  follows: 

1.  That  the  vas  deferens  having  been  displaced  in  the 
manner  usually  adopted  in  operations  for  varicocele 
the  spermatic  artery  does  not  accompan}’  it,  but  re- 
mains with  the  spermatic  veins. 

)2.  That  in  cases  of  varicocele  the  division  of  the 
main  trunk  of  the  spermatic  artery,  together  with  the 
veins,  if  the  ordinary  principles  of  surgical  cleanliness 
be  observed,  is  not  only  harmless  to  the  testicle,  but 
probably  aids  in  the  ultimate  relief  of  the  affection 
by  diminishing  the  pressure  of  blood  going  to  the  tes- 
tis at  the  time  when  almost  all  the  returning  veins  are 
suddenly  obliterated. 

3.  That  the  division  of  the  deferens,  spermatic 
artery,  and  spermatic  veins,  which  entails  a section  of 
apparently  the  whole  cord,  is  not  necessaril}^  followed 
by  sloughing,  or  even  subsequent  wasting,  of  the  tes- 
ticle, provided  that  a perfectly  aseptic  condition  of 
the  wound  is  maintained.  * 

With  reference  to  the  same  subject,  A.  W.  M.  Rob- 
son says  : 

“In  1886  I published  a series  of  ten  cases  of  vari- 
cocele treated  by  excision,  the  operation  differing  ver\" 
slightly  from  that  recommended  b}’  Mr.  Bennett  in 
his  paper  published  in  The  Lancet  of  Feb.  9,  1889.  I 
have  had  the  opportunit)'  of  seeing  many  of  these 
cases  since,  and  find  that  there  has  been  absolute!}' no 
atrophic  change  or  other  apparent  alteration  in  the 
testicle,  and  yet  in  all  of  them  not  only  was  the  bun- 
dle of  veins  but  a portion  of  the  spermatic  artery  re- 

*Lancet,  March  7,  1891. 

Brit.  Med.  Jour.  March  21st,  1891. 


i6g 


moved,  for  it  is  quite  easy,  as  Mr.  Bennett  says,  to 
see  the  open  mouth  of  the  artery  in  the  mass  of  tis- 
sue removed,  leaving  no  doubt  about  its  division.  In 
all  my  cases  an  aseptic  course  was  pursued,  and  in 
none  was  there  any  trouble  from  orchitis.” 


Fig.  4.  Fig.  5.  Fig.  6.  Fig.  7. 


big.  4. — Keyes’s  improved  needle  for  varicocele. 


170 


Fig.  5. — Keyes’s  varicocele  needle,  plain. 

Fig.  6. — Whitehead’s  varicocele  needle. 

Fig.  *7. — Reverdin’s  needle. 

Sir  James  Paget  reported  a case  of  Pyaemia  following 
subcutaneous  deligation.  Curling  spoke  of  several 
cases  of  enroulement  practiced  by  Roux,  in  which 
death  resulted.  Thievenow  had  a case  of  death  from 
septicaemia.  Howe  reported  a fatal  case  of  peritoni- 
tis after  ligature.  That  severe  pain  and  even  tetanus 
should  be  liable  to  occur  in  subcutaneous  deligation, 
is  not  surprising  if  we  take  into  consideration  the 
numerous  and  sensitive  nerve  filaments  which  suppl}' 
the  involved  parts.  The  inclusion  of  these  nervous 
structures  in  the  ligature  is  to  a great  extent  unavoid- 
able. The  danger  is  reduced  to  a minimum  however, 
by  care  in  separating  the  structures  of  the  varicocele, 
and  including  as  little  tissue  as  possible  in  the  liga- 
ture. 

I do  not,  however,  condemn  subcutaneous  deligation 
in  toto,  and  have  performed  it  myself  a number  of 
times.  In  proper  hands  and  under  some  circumstan- 
ces it  is  well  enough.  I believe  nevertheless,  that 
there  are  better  and  safer  methods. 

There  is  no  real  necessity  for  special  or  compli- 
cated needles  and  other  devices  in  this  operation, 
although  some  one  of  them  may  be  used  if  at  hand. 
Juniperized  silk  is  probably  the  best  substance  for 
ligature. 

After  proper  antiseptic  precautions  the  scrotum  is 
gathered  up  in  the  hand  and  transfixed  from  before 
backward  with  a small  tenotome  ; the  knife  is  then 
withdrawn  and  the  scrotum  allowed  to  drop  back  in 
place.  A fine  stiff  probe  (eyed)  threaded  with 
juniperized  silk  is  now  passed  through  the  punctures 
between  the  veins  and  vas  deferen,  and  passed  back 
outside  the  veins  still  carr5’ing  the  ligature,  to  emerge 
at  the  point  of  original  entry  in  front.  The  probe 
is  removed  and  the  ligature  tied  and  dropped. 
The  usual  precaution  of  rest  is  now  taken.  An}’ 
of  the  various  forms  of  needles  ma}’  be  used  if 
desired.  The  results  of  subcutaneous  deligation 


when  properly  performed  are  certainly  good,  a large 
proportion  of  cures  resulting.  This  in  a measure 
compensates  for  certain  undesirable  features  of  the 
method.  Fig. 

3 and  4.  There  is  little  choice 
between  open  deligation  without 
disturbance  of  the  veins  and  deliga- 
tion with  resections  of  the  veins 
excepting  possibly,  (this  being 
very  remote,)  the  additional  danger 
of  sepsis  in  the  latter.  Division  of 
the  veins  with  the  cautery  wire  is 
as  yet  untried,  but  in  spite  of  the 
favorable  report  of  its  originator,* 

I believe  it  to  be  the  most  dan- 
gerous operation  yet  devised.  The 
dangers  of  the  open  method  are  in  a 
less  degree  those  of  sub-cutaneous 
deligation  with  the  exception  of 
that  of  inclusion  of  the  vas  deferens 
— this  cannot  occur.  If  the  open 
method  be  selected  the  point  of 
election  should  be  as  high  up  as 
possible,  and  as  small  an  incision 
made  as  is  practicable  to  work 
through.  The  veins  are  thus  ligated 
m their  straight  portion  with  very 
little  mauling  about  of  the  cellular 
tissue.  The  higher  up  the  deliga- 
tion the  less  the  danger  of  sepsis, 
cellulitis  and  atrophy  of  the  testis, 
the  latter  advantage  being  possibly 
due  to  the  avoidance  of  trauma  of 
the  smaller  veins,  upon  which  we 
must  rely  for  return  circulation 
after  obliteration  of  the  vessels  composing  the  varix. 


Andrew’s  retention 
clamp 

for  varicocele. 

In 


a general  way  it  may  be  said  that  deligation  at  a single 
point  in  each  vein  is  safer  than  at  several  points  in  the 
same  vessel;  it  is  also  quite  as  effectual.  The  results 


*Gould. 


172 


of  the  open  method  performed  in  this  manner  are  excel- 
lent and  the  danger  under  antisepsis  is  very  remote. 

Deligation  with  Resectio7i  of  the  scrotum.— \ con- 
sider this  to  be  the  ideal  operation  in  by  far  the  majority 
of  cases  demanding  surgical  interference.  Much  de- 
pends on  the  method  of  performance; — the  important 
details  as  far  as  the  danger  to  life  is  concerned,  affect- 
ing chiefly  the  deligation.  Under  proper  antiseptic 
precautions  I do  not  believe  that  the  scrotal  amputa- 
tion complicates,  or  at  least  enhances  the  dangers  of 
the  operation.  Deligation  with  resection  is  indicated 
where  the  varix  is  large  and  the  scrotum  very  lax  and 
pendulous.  The  removal  of  the  latter  gives  the  best 
prophylaxis  against  recurrence  of  the  varix.  Thi. 
results  are  likely  to  be  better  than  those  attained  by 
any  of  the  other  methods. 


Lewis’  scrotal  clamp. 


6.  Resectioti  of  the  scrotum  is  the  safest  operation 
for  varicocele  and  according  to  Henry  is  a radical 
cure  in  the  true  sense  of  the  term.  He  reported 
fifty-nine  operations  some  years  ago,  which  as  far  as 
he  could  learn  were  radically  successful.  This  same 
operator  has  since  reported  a number  of  cases  at 
various  times,  for  which  he  claims  an  equal  degree  of 
success.  In  my  early  experience  with  Henr3  ’s  opera- 
tion I was  inclined  to  accept  the  statements  of  the 
ardent  advocates  of  the  method  without  much  question. 

A wider  experience  and  observation  has,  however, 
convinced  me  that  too  much  has  been  claimed  for  the 
operation.  To  be  sure,  as  Henry  naively  sa5's,  it 
makes  little  difference  if  the  operation  is  again  neces- 


173 


sary  after  a lapse  of  years,  as  the  method  is  perfectly 
safe,  but  this  is  begging  the  question  in  regard  to  an 
alleged  “radical  cure.”  In  very  large  varicoceles  the 


Fig.  10. 

(After  Wiekhaiii.) 

changes  in  the  texture  of  the  venous  walls  are  such 
that  pressure  and  support  alone  are  insufficient  to  se- 
cure restoration  of  their  natural  consistency  and  cali- 
ber, even  though  the  pressure  be  sufficiently  firm  and 
continuous.  There  is  little  elasticity  in  the  remain- 
portion  of  the  scrotum,  and  the  tone  of  the  partis 


174 


apt  to  remain  as  impaired  as  before  the  operation — the 
same  constitutional  conditions  prevailing.  It  is  my  opin- 
ion that  stretching  and  relaxation  of  the  new  “natural 
suspensory”  or  scrotum  will  recur  in  the  majority  of 
severe  cases  sooner  or  later.  The  varicocele  may  not 
be  as  severe  as  before  the  operation  and  the  more  urgent 
symptoms  may  be  relieved,  but  there  is  nothing  edify- 
ing in  the  spectacle  of  a good  sized  varix  a few  years, 
or  perhaps  months,  after  a so-called  radical  cure. 

I desire  to  do  the  method  full  justice  however,  and 
am  free  to  say  that  the  subjective  symptoms  do  not 
always  recur  pari  passu  with  a return  of  the  varix; 
but  I am  discussing  a “ radical  cure  ’ ’ and  hair-splitting 
is  unnecessary.  The  patient  is  apt  to  forget  the  original 
subjective  symptoms  and  gauge  the  value  received 
by  the  ocular  and  objective  evidence  at  his  command. 

In  moderate  varicoceles  and  in  quite  ycung  subjects 
the  scrotal  tissues  are  apt  to  retain  a certain  degree 
of  consistency  and  elasticity,  and  the  veins  have  not 
usually  entirely  lost  their  normal  tone.  Under  these 
circumstances  scrotal  resection  is  the  ideal  operation. 
It  is  far  better,  in  my  opinion,  for  a patient  to  submit 
to  this  operation  than  to  be  annoyed  by  suspensory'^ 
bandages  for  the  rest  of  his  days.  It  is  safe,  when 
properly  performed,  and  gives  an  ideal  result. 

One  of  the  most  systematic  operations  for  variocele 
is  that  advocated  by  M.  Edmond  Wickham.  This 
surgeon  uses  the  Horteloup  clamp  and  performs  the 
operation  with  the  strictest  antiseptic  precautions. 
The  novelty  of  his  method  consists  in  his  mode  of 
fastening  the  sutures.  The  sutures  are  passed  a 
short  distance  apart,  and  are  double;  at  one  extremity' 
they  are  fastened  to  a thin  strip  of  lead  moulded  to 
accurately  fit  the  curve  of  the  scrotum  after  its  cur- 
tailment. The  sutures  are  passed  through  between 
the  blades  of  the  clamp  before  its  removal.  Between 
each  suture  is  passed  a hare-lip  pin.  Small  sections 
of  lead  tubing  are  passed  over  the  ends  of  the  double 
sutures,  and  at  the  completion  of  the  operation  are 
clamped  down  firmly  in  a manner  similar  to  that  em- 
ploy'ed  with  split  shot. 


175 


I append  illustrations  of  Wickham’s  method,  not 
because  I recognize  its  superiority,  but  because  the 
cuts  represent  quite  accurately  the  proper  method  of 
application  of  all  forms  of  clamps  and  the  passage  of 
the  sutures.  As  already  remarked  in  connection  with 
the  Horteloup  clamp,  I am  inclined  to  believe  that 
there  is  likelihood  of  too  much  scrotum  being  left 
where  this  clamp  is  used  for  the  purpose  of  outlining 


Fig.  11. 


After  Wickham. 


176 


, Fig  12. 

the  proper  amount  of  tis- 
sue for  removal. 

In  describing  what  I be- 
lieve to  be  the  ideal  method 
for  large  varicoceles  it  is  not 
my  intention  to  advocate 
it  as  a routine  practice. 

The  surgeon  must  neces- 
sarily at  all  times  use  his 
best  judgment  and  select 
the  operation  apparently 
best  suited  to  the  exigences 
of  the  case  in  hand. 

I will  simply  describe  the 
method  which  I believe  to 
be  the  safest  and  nearest 
approach  to  a radical  cure 
in  the  vast  majority  of 
cases  of  pronounced  vari- 
cocele. I shall  not  follow 
the  usual  custom  of  claim- 
ing the  method  by  virtue 
of  some  little  modifications 
of  technique.  As  I have 
already  hinted,  the  ?-aison 
d'etre  of  so-called  spec- 
ial methods  usually  exists 
only  in  the  mind  of  the  op- 
erator. I do  not  know 
whether  this  particular 
combination  of  the  old  and 
new  is  practiced  by  others, 
nor  do  I consider  it  mate- 
rial to  the  subject  in  hand. 

If  it  is  so  practiced  the 
label  it  to  suit  himself,  providing  he  wull  permit  me 
to  use  the  label.* 


Henr}"’s  improved  scrotal 
clamp, 
operator  is  privileged  to 


*Since  this  article  was  written  I have  noted  the  following  by 
A B.  Barrow  ; 

" I have  simplified  the  operation  of  varicocele  slightly, 
making  the  incision  over  the  external  abdominal  ring  only,  and 


177 


The  bowels  having  been  emptied  by  a saline  or  cas- 
tor-oil. the  latter  being  perhaps  preferable,  the  scro- 
tum, pubes  and  thighs  are  thoroughly  scrubbed  with 
green  soap  and  bichloride  ‘Aoou  and  then  bathed  with 
a bichloride  solution  Vioon, 

This  completed  the  patient  is  anaesthetized  during 
which  process  the  scrotum  is  wrapped  in  a towel  wet 
with  the  bichloride  solution.  It  is  hardly  necessary 
to  say  that  the  operator  is  now  supposed  to  wash  his 
hands  and  remove  all  superfluous  subungual  organic 
matter.  Everything,  including  the  operator’s  con- 
science being  thus  prepared  and  all  instruments  hav- 
ing been  asepticised  by  boiling  water,  an  incision 
one  inch  or  a little  more  in  length  is  made  beginning 
just  below  the  external  abdominal  ring  and  parallel 
with  the  spermatic  cord.  This  is  carried  down  until 
the  cord  and  its  accompanying  veins  are  exposed. 
The  number  of  veins  varies  in  my  experience  ; they 
are  here  quite  straight  and  when  emptied  of  blood 


not  extending  it  into  the  scrotal  tissues  at  all,  as  I found  that  it 
was  quite  easy  to  pull  up  the  veins  into  this  limited  opening  and 
ligature  them;  and  in  this  situation  there  is  no  liability  to  injure 
the  vas  deferens,  so  I have  discontinued  the  use  of  the  pins  I then 
recommended.  But  I attach  the  same  importance  to  that  point 
in  which  I advocated  the  clearing  and  ligaturing  the  veins  first  at 
the  external  abdominal  ring,  where  it  is  easily  done;  and,  having 
cut  them  through,  to  pick  up  the  distal  ends  of  the  veins,  and 
lifting  them  up  to  strip  off  the  surrounding  tissues  of  the  cord  as 
low  as  the  upper  part  of  the  testicle;  then  apply  the  lower  liga- 
ture, cut  the  veins  through  again,  and  allow  the  testicle,  which 
has  been  drawn  up  to  the  wound,  to  slip  back  into  the  scrotum. 
In  this  way  I have  operated  upon  a large  number  of  cases,  in  a 
few  instances  removing  the  veins  of  both  sides  at  the  same  oper- 
ation, and  often  doing  the  operation  in  association  with  the  radi- 
cal cure  of  hernia,  and  I have  had  unvarying  success  both  as  re- 
gards the  rapidy  of  healing  of  the  wound,  the  cure  of  the  affec- 
tion, and  the  satisfactory  condition  of  the  testicle,  Several  cases 
have  been  afterward  admitted  into  the  services. 

“I  have  not  found  the  testicles  diminish  in  size  in  any  case, 
but,  on  the  contrary,  it  usually  increases.  In  some  cases  I have 
observed  that  there  is  a tendency  for  the  tunica  vaginalis  to  be- 
come slightly  distended  with  fluid  when  the  patient  first  begins 
to  walk  about,  but  this  condition  disappears  during  the  night 
when  the  patient  is  lying  down,” — Bril.  Med.  Jour.,  March,  21, 
1891. 


178 


quite  small.  The  cord  and  veins  are  hocked  with  an  an- 
eurism needle  out  of  the  wound  which  is  meanwhile 
occasionally  irrigated  with  bichloride  solution ; the 
veins  are  now  separated  and  several  of  the  larger  ones 
ligated  with  a single  ligature  of  medium  sized  juni- 
perized  silk  ; the  ligatures  are  cut  short  and  the  veins 
and  cord  dropped  back  in  place.  If  there  is  any  dif- 
ficulty in  reposition  of  the  cord  it  is  readily  overcome 


Fig.  13. 


oy  traction  on  the  testicle.  The  wound  is  now  irri- 
gated and  thoroughly  dried,  towels  instead  of  sponges 
being  used  for  this  purpose.  Sponges  are  far  inferior 
to  soft  dry  towels  for  checking  oozing  and  for  many 
reasons  to  be  preferred.  Several  fine  stitches  of  juni- 
perized  silk  are  now  inserted,  the  wound  closed  and 
dusted  with  iodoform.  During  the  remainder  of  the 
operation  the  wound  should  be  compressed  with  anti- 
septic gauze  by  an  attendant.  The  next  step  is  the 
application  of  the  clamp — I have  used  both  Henry’s 
and  a modification  of  King’s  clamp,*  but  an}^  other 
good  clamp  will  do.  (Fig.  13.)  Care  should  be  tak- 
en to  divide  each  side  of  the  scrotum  equall}^  and  to 
include  sufficient  tissue  in  the  clamp.  Asalread}'  ob- 
served it  is  well-nigh  impossible  to  remove  too  much. 
I have  operated  in  cases  where  I have  removed  the 
clamp  after  excision  of  the  scrotum  for  the  purpose 
of  ligating  a vessel  and  have  found  so  little  tissue  left 
that  I had  extreme  difficult}^  in  covering  in  the  testes, 
yet  the  new  scrotum  has  not  onty  proved  sufficient, 
but  I have  wondered  whether  it  would  not  have  been 
practicable  to  remove  more  tissue. 


^King’s  clamp  is  lighter  and  less  bunglesome  than  Henry's. 


tyg 


The  point  of  election  having  been  determined 
upon,  the  redundant  tissue  is  quickly  cut  away  along 
the  face  of  the  clamp.  Juniperized  silk  sutures  and 
harelip  pins  are  to  be  used  and  maybe  inserted  either 
before  or  after  the  excision,  but  always  before  remov- 
ing the  clamp.  There  should  be  as  little  delay  as 
possible,  as  the  prolonged  pressure  of  the  clamp  pro- 
duces more  or  less  bruising  of  the  loose  scrotal  tissues 
which  is  not  conducive  to  prompt  union.  Three  or 
four  pins  are  usually  enough;  these  should  be  inserted 
at  divided  intervals  and  the  silk  sutures  interposed  in 
sufficient  number  to  prevent  gaping  and  maintain  ac- 
currate  apposition.  Henry  covers  the  heads  of  the 
pins  with  sealing  wax  and  embeds  their  points  in  small 
corks. 

Fig.  14. 


A plan  which  is  perhaps  better  and  one  which  I oc- 
casionally practice  is  to  pass  reinforcing  sutures  of 
silver  wire  instead  of  the  pins.  A single  strand  of 
wire  is  used  and  its  ends  knotted  upon  small  rubber 
buttons  or  fixed  in  split  shot.  The  tension  is  so  ex- 


i8o 


treme  that  something  more  than  ordinary  sutures  is 
required. 

The  secondary  blade  of  the  clamp  having  been 
removed  the  sutures  are  lightly  tied  and  the  main 
clamp  removed.  If  the  sutures  be  permanently  tied 
before  removal  of  the  clamp  the  surgeon  may  have  to 
reopen  the  wound  to  tie  some  spouting  vessel.  Ves- 
sels should  be  twisted  where  possible,  or  traversed  by 
a suture.  An  assistant  must  now  press  back  the  testes 
else  they  will  pop  out  in  a truly  demoralizing  fashion. 
I well  remember  my  first  experience  in  this  respect. 

I wondered  where  on  earth  I was  going  to  get  skin 
enough  to  cover  those  obstreperous  appendages. 

All  hemorrhage  having  been  checked  the  wound  is 
permanently  closed.  Too  much  care  cannot  be  taken 
in  checking  hemorrhage,  as  there  is  an  especial  ten- 
dency to  venous  oozing.  The  formation  of  a clot  be- 
neath the  wound  will  not  only  prove  a source  of 
septic  danger,  but  will  prevent  speedy  union.  There 
is  also  the  danger  of  serious  hemorrhage  of  a passive 
character.  To  one  unfamiliar  with  operations  about 
these  parts  the  tendency  to  prolonged  oozing  is  pecu- 
liar; I have  noted  it  for  several  da}’s  after  a most  care- 
ful operation  for  varicocele. 

The  danger  of  hemorrhage  is  in  a great  measure 
dependent  on  the  constitutional  condition  of  the 
patient,  as  shown  in  one  of  my  cases. 

The  occurrence  of  concealed  hemorrhage  and  for- 
mation of  clot  can  be  readily  avoided  by  the  insertion 
of  a small  drainage  tube  along  the  line  of  suture  at 
the  lower  angle  of  the  wound.  I prefer  for  this  pur- 
pose decalcified  bone,  but  rubber  will,  of  course, 
answer  the  purpose. 

Henry  uses  adhesive  plaster  as  an  additional  sup- 
port to  the  wound,  but  I have  found  graduated  com- 
presses to  be  all  that  is  required. 

Having  closed  the  wound  and  made  provision  for 
drainage,  the  parts  are  irrigated  with  the  bichloride 
solution,  dried,  the  edges  sprinkled  with  iodoform  and 
a piece  of  oiled  silk  or  protective  laid  along  the  edges 


i8i 


to  prevent  adhesion  of  the  subsequent  dressings.  A 
quantity  of  borated  cotton  and  antiseptic  gauze  in 
which  a hole  has  been  cut  for  the  penis  is  now  applied 
and  the  whole  secured  by  a three-tailed  bandage 
secured  at  the  waist.  A light  diet  should  be  advised, 
and  no  attempt  made  to  move  the  bowels  for  four  or 
five  days.  When  a movement  does  occur  the  parts 
should  be  carefully  supported  and  a bedpan  used. 

The  sutures  should  not  be  removed  for  six  or  seven 
days  or  gaping  will  quite  likely  occur.  So  extreme 
is  the  tension  when  the  operation  is  properly  per- 
formed that  gaping  is  quite  frequent.  The  drainage 
tube  should  be  removed  in  three  or  four  days.  The 
silver  pins,  or  wire  sutures,  as  the  case  may  be,  can 
be  allowed  to  remain  for  several  days  longer  if  neces- 
sary. An  excellent  plan,  where  gaping  occurs,  is  the 
application  of  stout  mole-skin  plaster  on  either  side 
of  the  wound;  through  the  edges  of  the  plaster  holes 
are  punched  and  the  two  strips  laced  together  with  a 
stout  silk  or  hempen  thread,  shoe-string  fashion. 
The  strips  of  plaster  should  extend  well  out  to  the 
thighs.  Although  a speedy  union  is  desirable  as 
lessening  the  liability  to  inflammatory  complications 
and  enabling  the  patient  to  get  about  soon,  gaping  of 
the  wound  has  some  compensatory  advantages.  The 
cases  which  heal  by  granulation  yield  a firmer  support 
to  the  varix  from  cicatricial  contraction  and  inflam- 
matory thickening.  This  was  well  illustrated  by  one 
of  my  cases  in  which  erysipelas  occured. 

The  patient  may  be  allowed  to  get  up  in  two  weeks 
if  no  complications  arise. 

operations  for  varicocele  now  comprise  forty 
cases  of  all  methods,  ten  of  which  have  been  subcu 
taneous  deligations  of  the  veins,  sixteen  of  simple  re- 
section of  the  scrotum,  four  of  resection  of  the  scro- 
tum with  ligation  of  the  veins  at  several  points,  one  of 
open  deligation  with  resection  of  the  veins,  one  of 
open  deligation  without  resection  of  veins,  and  eight 
of  ligation  of  the  veins  high  up  with  resection  of  the 
scrotum.  A recital  of  these  cases  in  detail  would  be 


i82 


monotonous,  hence  I will  give  only  the  points  of  in- 
terest developed  by  their  study.  I have  had  no  deaths 
and  but  few  cases  in  which  there  was  serious  reason 
for  alarm.  In  some  few  instances,  however,  there 

14 


Application  of  King's  Clamp. 

Fig.  i5. 

were  certain  features  which  caused  me  considerable 
uneasiness  for  a time. 

The  youngest  patient  operated  on  was  eighteen  and 
the  oldest  forty  years  of  age.  Most  of  the  patients 
were  between  twenty  and  thirty.  The  duration  of  the 
affection  varied,  according  to  the  patients’  statements, 
from  one  to  twenty  years.  The  question  of  duration, 
however,  is  not  of  importance,  nor  can  it  be  arbitrarily 
settled  in  any  case.  The  duration  of  varicocele  is 


necessarily  a relative  matter,  and  implies  the  period 
since  the  condition  was  first  brought  to  the  patient’s 
attention.  Obviously  the  sexual  hypochondriac  who 
proverbially  seeks  for  what  he  does  not  wish  to  find, 
is  likely  to  discover  the  tumor  earlier  than  one  in 
whom  the  sexual  functions  are  not  a matter  of  es- 
pecial concern.  Patients  with  neuralgic  manifesta- 
tions, referable  to  the  cord,  testes  or  penis,  are  apt  to 
discover  their  varix  at  an  early  period. 

The  causes  of  varicocele,  as  suggested  by  my  cases, 
is  also  difficult  to  outline  arbitrarily.  Masturbation 
and  sexual  excesses  are  the  causes  which  are  usually 
assigned  for  varicocele.  Often,  however,  sexual  ex- 
cesses do  not  appear  to  be  sufficient  per  se  to  account 
for  varicocele,  but  no  other  cause  is  discoverable.  It 
is  certain  that  only  a small  percentage  of  masturba- 
tors have  varicocele.  As,  however,  nearly  all  boys 
masturbate,  it  is  safe  to  say  that  about  all  subjects  of 
varicocele  have;  hence  the  post  hoc  ergo  propter  hoc  ar- 
gument is  quite  natural.  1 believe  that  I am.  safe  in 
saying  the  sexual  abuse  alone  never  causes  varico- 
cele, and  that  it  is  an  effective  cause  in  direct  pro- 
portion as  it  is  associated  with  some  constitutional 
fault  involving  vaso  motor  perturbation  and  laxity 
of  tissue,  with  especial  reference  to  the  venous 
walls. 

As  illustrative  of  the  important  relation  of  general 
vascular  atonicity  to  varicocele,  one  of  my  cases  al- 
ready mentioned  is  certainly  striking.  This  case  was 
under  the  charge  of  Dr.  S.  V.  Clevenger,  one  of  our 
leading  neurologists,  who  was  treating  him  for  epi- 
lepsy. The  doctor  observed  scrotal  haemidrosis,  and 
referred  the  patient  to  me  as  a curiosity.  On  exami- 
nation I found  a large  varicocele,  which  the  patient 
claimed  was  causing  him  great  annoyance  by  its 
weight  and  the  consequent  dragging  upon  the  cord 
and  back  ache.  On  inquiry  I elicited  the  fact  that  he 
was  exceedingly  hypochondriacal.  A peculiar  feature 
of  the  case  was  the  fact  that  the  seminal  emissions, 
like  the  sudoriparous  secretion  of  the  scrotum,  was 


184 


heavily  tinged  with  blood.  Urethrametry  revealed 
several  strictures  in  the  penile  urethra. 

As  the  epileptic  attacks  were  infrequent  and  had 
developed  since  the  acquirement  of  the  strictures — 
and  the  patient  claimed  since  the  development  of  the 
varicocele — it  was  thought  advisable  to  operate.  As 
I considered  the  hemorrhagic  secretions  to  be  a fair 
warning  of  the  danger  of  hemorrhage,  I ligated  the 
varix  subcutaneously,  and  at  the  same  time  performed 
a dilating  urethrotomy.  As  I anticipated,  a terrific 
hemorrhage  from  the  urethra  resulted.  The  bleed- 
ing continued  for  three  daj'S  and  necessitated  the 
constant  presence  of  an  attendant  who  applied  pres- 
sure by  an  ice  bag  during  that  time.  There  was  con- 
siderable induration  of  the  veins  and  a sharp  orchitis 
following  the  ligature.  The  result  however  has  been 
excellent  so  far.  The  epileptic  attack  which  was  ex- 
pected at  the  time  of  the  operation  has  been  post- 
poned for  nearly  four  months.  I do  not  say  that  this 
fact  is  proof  of  the  causal  relation  of  the  stricture  and 
the  varicocele  to  the  epilepsjc  Time  may  show  this 
however.  Like  many  operations  upon  the  skull  for 
epileps}^,  the  result  in  this  case  maj'  be  due  to  a 
temporary  revulsive  effect  upon  the  nervous  mechan- 
ism which  has  merely  postponed  the  usual  explosion. 
I will  state  however  that  the  patient’s  general  health 
is  much  better,  and  that  he  has  markedh' increased  in 
weight. 

Several  of  mj^  cases  have  apparently  followed  an 
epididymitis  or  traumatism.  In  how  far  these  causes 
were  responsible  for  the  varix  in  these  cases  I am  un- 
able to  say.  Very  often  the  only  relation  between 
epididymitis  or  injury  and  varicocele,  is  the  fact 
that  the  latter  has  been  first  discovered  after  these 
accidents.  Personally  I think  that  either  of  these 
causes  may  be  operative.  I have  had  one  case  of 
varicocele  undoubtedly  due  to  athletic  strain.  All 
authors  I believe,  admit  the  possibilitj'  of  a kick  pro- 
ducing varicocele.  In  several  instances  I have  had 
patients  with  small  varioceles  who  happened  to  be 


under  observation,  wlrose  varices  increased  after  an 
attack  of  epididymitis.  Anything  which  will  impair 
the  tone  of  the  involved  part,  or  induce  circulatory 
obstruction,  should  be  operative  in  producing  or  at 
least  aggravating  varicocele. 

I have  operated  on  two  jockeys  each  of  whom  attrib- 
uted his  varicocele  to  excessive  horseback  riding,  in 
one  case  the  patient  recalled  an  injury  in  springing 
into  the  saddle.  There  is  no  question  in  my  mind  as 
to  the  causal  influence  of  excessive  horseback  riding 
in  producing  varicocele.  All  old  cavalrymen  will 
support  this  opinion.  The  records  of  the  pension 
office  afford  abundant  proof.  Dr.  James  A.  Lydston 
who  has  been  connected  with  the  pension  bureau  for 
some  years,  informs  me  that  varicocele  is  one  of  the 
most  frequent  disabilities  presented  to  the  attention 
of  the  department,  and  that  it  is  especially  prevalent 
among  those  who  served  in  the  cavalry.  How  im- 
portant the  appearance  of.  two  jockeys  is  in  this  con- 
nection I cannot  say;  it  may  have  been  a coincidence, 
as  I am  unable  to  state  that  the  prevalence  of  vari- 
cocele among  jocke3?s  is  a matter  of  comment.  Other 
things  being  equal,  they  would  be  less  likely  than 
other  riders  to  injure  themselves,  as  they  ride  on 
plain  saddles,  and  they  cannot  therefore  experience 
the  disagreeable  effects  of  a blow  with  a pommel. 
Jockeys  as  a class  are  young,  healthy,  light  weight 
subjects  who  are  well  kept  and  not  subject  to  vascular 
debility. 

The  symptoms  for  which  the  patients  upon  whom 
I have  operated  have  sought  relief  have  varied.  In 
several  instances  the  principal  annoyance  complained 
of  was  the  deformity.  One  of  my  patients,  for  ex- 
ampie,  was  annoyed  by  the  frequent  comments  which 
were  made  upon  his  appearance,  his  varicocele  being 
so  biuky  as  to  be  quite  prominent  even  when  his 
trov:-ers  were  amply  large.  There  was  no  other 
syp'^4om  in  his  case  which  was  of  any  particular 
moment. 

In  several  other  cases  there  was  noticeable  deform- 


ity,  but  associated  with  it  were  sexual  hypochondria- 
sis and  various  reflex  disturbances.  In  some  in- 
stances mechanical  discomfort  has  been  chiefly  com- 
plained of.  In  several  cases  intertrigo,  and  in  one 
instance  severe  chronic  eczema,  constituted  the  chief 
source  of  annoyance.  Pain  in  the  back,  shooting 
pains  along  the  cord  and  penis,  and  neuralgia  of  the 
testes  have  been  frequent.  In  some  cases  irritabilit}’ 
of  the  bladder  has  been  complained  of.  In  nearl}’ 
all  instances  sexual  hypochondriasis,  with  or  without 
spermatorrhoea,  has  been  pronounced.  I do  not  wish 
to  be  understood  as  asserting  that  all  of  the  symp- 
toms for  which  the  patients  sought  relief  -were  neces- 
sarily dependent  upon  the  varicocele.  The  nocturnal 
pollutions,  spermatorrhoea  and  prostatorrhoea,  might 
have  been  due  in  many  of  my  cases  not  to  the  varix 
per  se,  but  to  the  same  underlying  cause  as  the  varix. 
In  several  instances  the  principal  symptoms  were  not 
removed  by  the  operation. 

In  but  one  case  have  I had  sufficient  hemorrhage 
to  give  rise  to  any  particular  annoyance.  In  this  case 
there  was  a tendency  to  hemophilia.  This,  with  m}' 
failure  to  use  a drainage  tube,  resulted  in  a concealed 
hemorrhage,  the  formation  of  a clot,  and  after  re- 
moval of  the  latter,  free  passage  oozing  for  some 
days.  In  this  case  there  was  the  most  extensive 
ecchymosis  that  I have  ever  seen,  the  tissues  from 
the  umbilicus  down  to  the  middle  of  the  thighs 
being  as  black  as  extravasated  blood  could  make 
them.  The  result,  although  alarming  in  appearance, 
was  not  a matter  of  concern,  but  the  patient  became 
ver}'  much  frightened  at  what  was  apparently,  as  he 
expressed  it,  a general  mortification.  A tendency  to 
ecchymosis  exists  in  all  cases  of  operation  for  vari- 
cocele, and  this  should  be  remembered,  else  both  sur- 
geon and  patient  are  apt  to  be  demoralized  b}'  the 
consequent  appearance  of  the  parts.  In  several 
other  instances  there  has  been  a tendencj^  to  oozing 
for  some  days,  thus  precluding  the  possibility  of  pri- 
mary union. 


i87 


The  use  of  the  drainage  tube  is,  in  my  estimation, 
one  of  the  most  valuable  points  in  all  operations  in- 
volving resection  of  the  scrotum.  Concealed  hemor- 
rhage, tension  and  sepsis  are  not  liable  to  occur  when 
the  tube  is  used;  there  is  unquestionably  danger  of 
these  accidents  without  it.  As  long  as  marked  ooz- 
ing persists  the  tube  should  be  allowed  to  remain. 
Should  severe  hemorrhage  occur  after  the  operation 
has  been  completed,  the  tube  facilitates  hot  water  ir- 
rigation or  the  application  of  styptics,  the  former  be- 
ing the  best  haemostatic. 

The  healing  of  the  wound  in  a fair  proportion  of 
my  cases  of  resection  of  the  scrotum  has  been  by 
first  intention;  but  I have  found  that  there  is  in  many 
cases  a tendency  to  gaping,  even  though  the  sutures 
be  allowed  to  remain  for  a week  or  more.  Indeed,  I 
am  inclined  to  believe  that  when  there  is  no  tendency 
to  gaping,  hardly  enough  scrotum  has  been  removed. 
The  gaping  is  always  due  to  the  extreme  tension 
upon  the  parts  incident  to  a thorough  operation.  It 
may  be  prevented  in  many  cases  by  allowing  the 
sutures  to  remain  in  for  some  little  time.  If  juni- 
perized  silk  and  silver  wire  be  used,  as  I have  sug- 
gested, the  stitches  can  be  allowed  to  remain  in  from 
five  to  eight  days  with  impunity. 

In  several  instances  I have  had  slight  sloughing  of 
the  scrotum,  evidently  from  extreme  tension.  In 
these  cases,  however,  the  result  has  been  even  better 
than  those  in  which  primary  union  occurred.  No 
matter  how  much  tissue  may  slough  the  parts  become 
covered  in  by  an  excellent  scrotum  with  almost  mar- 
vellous rapidity.  Although  the  fit  is  decidedly  snug 
at  first,  the  testes  soon  accommodate  themselves  to 
their  new  investment.  I have  never  seen  a more  de- 
lighted patient  than  one  of  mine  in  whom  cellulitis 
occurred  as  a consequence  of  infection  after  opera- 
tion. 

I recall  a case  of  cellulitis  of  the  scrotum,  not 
however  following  operation,  that  occurred  some 
years  ago  in  the  Nev'  York  Charity  Hospital,  in  which 


i88 


testes  were  bared  completel}',  }’et  by  judicious 
Suiapping  and  occasional  stimulation  cf  the  granula- 
tions a good  scrotum  was  finally  secured.  I saw  sev- 
eral other  cases  of  scrotal  cellulitis  in  the  New  York 
State  Emigration  Hospital  during  my  term  of  service 
in  that  institution.  Contrary  to  the  rule  in  such 
cases,  none  of  these  died.  In  all  there  was  extensive 
sloughing  of  the  scrotum,  but  repair  once  begun  was 
very  rapid.  Such  cases  teach  us  that  in  resection  of 
the  scrotum  there  should  be  little  fear  of  excising  too 
much  tissue.  The  more  excised  the  better  the  result; 
and  while  it  is  always  desirable  to  obtain  primary 
union  where  possible,  I feel  justified  in  saying  that 
the  more  gaping,  the  better  the  result.  Cellulitis, 
/.  e.  erysipelas,  is  not  a source  of  danger  in  resection 
of  the  scrotum  unless  direct  infection  occurs.  This 
was  the  explanation  in  one  of  my  hospital  cases 
which  I have  already  mentioned.  The  failure  of  the 
wound  to  unite  promptly  is  undoubtedly  in  some 
cases  of  scrotal  resection  due  in  a measure  to  the 
prolonged  pressure  of  the  clamp.  Sloughing  ma}-  be 
partially  explained  in  this  manner.  As  I have  al- 
ready remarked,  my  faith  in  resection  of  the  scrotum 
as  a radical  cure  for  varicocele  has  been  somewhat 
shaken  by  several  of  ' my  cases. 

In  one  instance  I have  had  an  opportunity  to 
watch  the  gentleman  for  nine  }’ears  since  the  opera- 
tion, and  although  I removed  all  the  tissue  necessar}’ 
to  an  ideal  operation  in  this  case,  the  varix  which 
was  a very  large  one  has  recurred,  and  is  now  nearly 
as  large  as  ever.  The  symptoms  however  for  which 
he  sought  relief,  have  not  returned.  In  two  other 
cases  there  has  been  a moderate  recurrence.  The 
objection  may  be  urged  that  I have,  not  taken  off 
enough  scrotum.  My  conscience  is  clear  upon  this 
point  however,  as  I have  invariable  taken  off  all  I 
could  in  reason  and  still  retain  a covering  for  the 
testes. 

My  operations  of  subcutaneous  aeligations  have 
been  successful,  but  on  the  average  have  given  me 


i8g 


more  uneasiness  and  trouble  than  those  in  which  I 
performed  the  open  operation.  Induration,  pain  and 
orchitis  are  some  of  the  disagreeable  features  which  I 
have  experienced  from  this  method  of  operation.  I 
have  found  that  the  operation  of  tying  the  veins  low 
down  is  much  more  objectionable  from  this  stand- 
point than  that  involving  ligation  higher  up  as  in  the 
combined  operation  which  I have  recommended.  It 
is  obviously  safer  to  ligate  the  veins  at  their  compar- 
atively straight  portion,  where  the  changes  in  the 
vascular  walls  are  at  a minimum,  and  there  is  the 
least  necessity  for  mauling  about  the  investments  of 
the  testes  and  tearing  up  the  planes  of  areolar  tissue. 

I have  already  given  my  reasons  for  advocating  the 
combined  operation.  In  one  of  my  cases  of  combined 
operation,  "I  ligated  the  vessels  at  several  points 
rather  low  down.  This  patient  did  fairly  well  for  two 
weaks,  when  he  arose  against  orders,  or  rather  over- 
exerted himself  when  allowed  to  sit  up.  As  a conse- 
quence, phlebitis,  cellulitis  and  consequent  slight 
suppuration  developed.  During  convalescence  this 
patient  developed  severe  la  with  marked  pul- 

monary symptoms,  haemoptysis  being  profuse,  giving 
me  great  apprehensions  of  pyaemia  with  embolic 
pneumonia,  etc.  Although  never  very  strong  lunged, 
this  patient  perfectly  recovered. 

In  four  or  five  cases  stricture  existed  and  urethro- 
tomy was  performed  simultaneously  with  the  opera- 
tion for  varix.  I can  see  no  objection  to  this  pro- 
cedure, and  I have  had  but  one  case  in  which  the 
operation  upon  the  urethra  afforded  any  complication. 
This  instance,  already  alluded  to,  was  one  in  which 
severe  urethral  hemorrhage  resulted. 

Two  cases  have  come  under  my  observation  which 
suggested  the  possible  development  of  hydrocele  as 
a result  of  operation  for  varicocele.  In  one  of  these 
cases,  operated  on  by  me  several  years  ago  by  sub 
cutaneous  deligation,  I again  operated  a short 
time  since  for  an  enc}’sted  hydrocele  upon  the  same, 
side.  In  another  instance  I operated  for  hydrocele  in 


a case  in  which  subcutaneous  deligation  had  been 
previously  perlormed  for  varicocele  of  the  same  side 
by  another  practitioner.  The  patient  was  complaining 
of  the  same  symptoms,  according  to  his  statement, 
that  had  characterized  the  original  varicocele.  My 
operation  by  hydrocele,  although  perfectly  successful 
per  se,  has  not  relieved  the  symptoms  from  which  he 
was  suffering.  He  is  now  giving  me  a great  deal  of 
annoyance  by  his  complaints  of  severe  neuralgia  of 
the  testicles.  The  irritation  of  sunken  sutures,  which 
had  accidentally  traversed  the  tunica  vaginalis,  or 
obstructed  venous  circulation,  plus  irritation,  might 
account  for  these  cases.  In  ligating  low  down  the 
tunica  vaginalis  is  apt  to  be  quite  roughly  handled,  if 
not  actually  traversed  by  the  ligature.  Acute  h}'dro- 
cele  is  a very  frequent  element  in  the  swelling  result- 
ing from  ligature  of  the  varix.  As  already  remarked, 
the  testis  itself  may  be  involved.  Injury  of  the  fascial 
envelopments  of  the  cord  high  up  is  not  important 
and  is  a necessary  factor  in  the  operation  which  I 
have  suggested. 

I have  never  performed  an  operation  for  double 
varicocele.  Indeed,  I have  met  with  no  case  which, 
to  my  mind,  required  such  operation.  Even  though 
a case  of  double  varicocele  should  apparently  require 
a double  operation,  I should  hesitate  to  incur  the  risk 
of  atrophy  of  both  testes  slight  though  I believe  it  to  be. 
In  ordinary  single  operations  the  risk  of  atrophy  is 
doubtless  overrated.  This  is  probably  due  to  (1)  the 
relative  appearance  of  shrinkage  incidental  to  the  sub- 
traction of  the  swelling  of  the  varix  per  se.  (2)  Contin- 
uation of  atrophy,  which  was  steadily  progressing  prior 
to  operation.  (3)  Atrophy  due  to  embolism,  syphilis, 
epididymitis,  etc.  Theoretical  considerations,  how- 
ever, do  not  alwa}'s  mollify  the  patient  where  actual 
atrophy  of  the  testes  occurs.  It  will  be  remembered  that 
Delpech  was  assassinated  by  a man  upon  whom  hehad 
performed  a double  deligation  for  varicocele  some  years 
before.  On  autopsy  the  murderer’s  testes  rvere  found  to 
be  soft  and  shrunken,  presumably  from  the  operation. 


I have  had  no  case  in  which  atrophy  of  the  testes 
has  followed  an  operation,  and  have  had  several  of 
scrotal  resection,  in  which  the  testes  became  firmer 
and  larger  after  the  operation.  Among  my  cases  was 
one  of  scrotal  haematocele,  resulting  from  the  injury 
of  a large  varicocele.  In  this  case  suppuration  oc- 
curred, and  I was  obliged  to  lay  the  part  open;  as  soon 
as  it  was  healthily  granulating  I removed  the  pendu- 
lous scrotum  with  an  excellent  result.  While  I have 
not  been  able  to  follow  all  of  my  cases  for  a great 
length  of  time,  the  immediate  results  have  been  emi- 
nently satisfactory,  and  in  those  cases  which  I have 
been  able  to  follow  for  a period  of  several  years, 
I have  no  occasion  to  regret  the  operation.  In  the 
majority  of  instances  the  relief  obtained  has  been  so 
marked  that  the  patients  were  greatly  delighted. 
That  this  has  alwa5^s  been  a physical  result  of  the  oper- 
ation I do  not  claim,  nor  do  I think  that  under  the 
circumstances  it  is  a question  of  great  importance. 

In  general  I have  found  that  the  combined  oper- 
ation of  high  ligation  of  the  veins  with  resection  has 
been -much  better  from  the  standpoint  of  economy  of 
time  than  the  subcutaneous  or  ordinary  open  oper- 
ations of  ligation.  Painful  induration  and  swelling  of 
the  testes  with  consequent  disability  and  impeded 
locomotion  are  very  frequent  in  my  experience  when 
these  operations  of  deligation  have  been  performed. 

In  nearly  all  of  my  cases,  there  has  been  a marked 
improvement  in  the  patient’s  mental  condition.  Hypo- 
chondriasis has  been  relieved  and  sexual  vigor  im- 
proved or  restored.  Pain  has  been  relieved  in  most 
instances.  A notable  exception  is  the  case  already 
mentioned,  in  which  h3?drocele  followed  an  operation 
for  varicocele  and  severe  pain  persisted  after  cure 
of  the  hydrocele. 


OBSERVATIONS  ON  STRICTURE  OF 
THE  URETHRA. 


It  is  not  my  intention  to  attempt  the  consideration 
of  the  entire  subject  of  stricture  of  the  urethra  in  this 
paper  ; it  would  not  only  be  tiresome,  but  of  little 
practical  value.  I desire,  however,  to  call  attention 
to  a few  points  which  have  appeared  to  me  suggestive 
and  practical.  In  presenting  these  points  my  remarks 
must,  of  necessity,  be  of  a more  or  less  desultory 
character. 

The  causes  of  stricture  are  too  familiar  to  require 
much  discussion.  There  is  one  point,  however,  in 
which  I beg  leave  to  differ  with  the  accepted  authori- 
ties upon  this  subject.  It  is  asserted  that  it  is  upon 
the  long  continuance  rather  than  the  severity  of 
urethral  inflammation  that  the  formation  of  stricture 
depends.  It  will  nevertheless  be  found  that  the  so- 
called  long  continued  inflammation  either  consists  of 
a series  of  bastard  claps,  coming  on  at  greater  or 
lesser  intervals,  or  of  a chronic  and  continuous  patho- 
logical process  following  directly  in  the  wake  of  a 
virulent  urethritis.  Both  these  conditions  are  de- 
pendent upon  the  damage  done  by  the  primary 
virulent  process,  and  the  probability  of  their  occur- 
rence is  directly  proportionate  to  the  severity  of  the 
primary  attack.  In  brief,  stricture  does  not  form  be- 
cause the  inflammation  is  long  continued,  but  the  in- 
flammation is  protracted  because  a stricture,  or  the 


194 


foundation  for  it,  was  formed  during  the  acute 
urethritis. 

The  direct  relation  of  stricture  to  the  acuteness  of 
the  primary  inflammation  will  appear  when  the  me- 
chanical factor  in  the  localization  of  stricture  is  taken 
into  consideration.  The  explanations  which  have 
been  advanced  to  account  for  the  localization  of 
stricture  at  one  point  in  the  canal  rather  than  another, 
have  seemed  to  me  unsatisfactory.  By  the  considera- 
tion of  a very  simple  mechanical  factor,  however,  the 
explanation  appears  quite  simple.  I believe  that 
friction  is  the  determining  element  in  the  causation 
of  all  strictures  not  due  directly  to  chemical  or  me- 
chanical violence. 

The  urethra  is  by  no  means  a passive  structure, 
but  is  at  greater  or  lesser  intervals  called  into  func- 
tional activity;  the  particular  function  which  concerns 
us  here  being  that  of  urination.  We  will  consider  the 
urethra  for  our  present  purpose  as  an  elastic  tube, 
comparable  to  a section  of  rubber  hose,  through  which, 
at  variable  intervals,  a certain  quantit}'  of  fluid  is 
forced  at  a certain  degree  of  hydrostatic  pressure. 
This  tube  is  not  uniformly  distensible,  but  is  narrower 
at  some  points  than  others.  The  points  of  normal 
contraction  are  too  well  known  to  require  description. 
In  addition  to  these  points  of  normal  and  absolute 
contraction,  I believe  that  there  are  in  the  pendulous 
portion  of  the  canal  points  of  relative  inelasticity  and 
indistensibility.  These  are  the  so-called  points  of 
normal  contraction  of  Weir  and  others,  and  constitute 
a large  proportion  of  the  strictures  of  large  caliber  of 
Otis.  They  are  the  battle-ground  of  the  warring  fac- 
tions, among  whom  the  chief  bone  of  contention  is, 
“to  cut  or  not  to  cut.”  And  I hope  to  be  able  to  show 
where  the  “rub”  comes  in. 

When  the  urethra  is  in  its  normal  condition  there  is 
no  abnormal  strain  at  any  point  in  the  canal ; and 
while  it  may  balloon  out  unequally  under  the  pressure 
of  the  escaping  urine,  there  is  no  injurious  friction. 
Now,  supposing  the  caliber  of  the  urethra  to  be  dimin- 
ished by  inflammatory  infiltration  to  one-half,  or — if  we 
take  its  normal  property  of  distensibility  into  consid- 
eration— perhaps  one-tenth  its  normal  capacity",  the 
same  degree  of  hydrostatic  pressure  prevailing,  what 


193 


is  the  consequence?  Necessarily  friction.  And  where 
is  that  friction  the  greatest  ? Obviously,  at  the  points 
of  least  distensibility — i.  e.,  at  the  points  of  normal 
contraction  and  of  relative  inelasticity.  These  points 
are  either  at  the  anatomical  lines  of  demarkation  of  the 
divisions  of  the  canal,  or  in  situations  where  the  elastic 
and  muscular  elements  of  the  urethra  are  sparse  as 
compared  with  the  fibro-connective  tissue.  A very 
simple  analogy  will  show  the  relation  of  these  two 
conditions  to  the  friction  alluded  to.  If  a string  be 
tied  about  a rubber  tube  so  as  to  constrict  it,  we  have 
a condition  similar  to  a point  of  normal  urethral  con- 
traction. Tie  another  string  about  the  tube  in  such  a 
manner  that,  while  it  does  not  constrict  it,  there  is  a 
restriction  of  expansion  under  hydrostatic  pressure, 
and  we  have  a point  of  relative  inelasticity.  In  my 
opinion  these  points  of  relative  inelasticity  can  be 
demonstrated  in  almost  any  urethra.  Regarding  the 
actual  points  of  normal  contraction,  there  is  of  course 
no  question. 

Using  this  same  rubber  tube  as  an  illustration,  we 
will  diminish  its  caliber  throughout,  leaving  the  strings 
in  situ.  We  will  now  apply  the  hydrostatic  pressure 
at  frequent  intervals  and  consider  theresult.  Obviously 
there  will  soon  be  a wearing  away  of  the  tube  at  the 
site  of  the  strings;  and  there  is  the  rub  in  the  case  of 
the  urethra. 

We  will  now  add  another  element  to  the  wearing 
process.  In  the  course  of  acute  urethritis,  there  is  a 
tendency  to  a rapid  formation  of  epithelium.  This  is 
a reparative,  a conservative  process,  but  unfortunately 
a certain  biological  law  comes  into  play  here,  viz:  In 
inverse  proportion  to  the  degree  as  differentiation  of 
cells  is  their  rapidity  of  proliferation,  and  their  ten- 
dency to  degeneration.  The  consequence  of  this  law 
is  an  erosion  at  the  point  of  friction,  and  secondarily, 
a plastic  deposit  to  resist  strain.  Comment  upon  this 
is  not  necessary.  The  subsequent  metamorphosis  of 
this  deposit  is  well  known.  In  the  pendulous  urethra 
especially,  and  probably  also  in  the  fixed  portion,  the 
plastic  deposit  ma}"  possibly  absorb,  but  the  friction 
remains  and  a gleet  is  often  kept  up.  The  points  of 
normal  contraction  and  relative  inelasticity  have  now 
become  of  pathological  significance. 


ig6 


Now,  I wish  to  ask  what  difference  it  makes  whether 
these  points  were  primarily  present  in  the  canal  as 
normal  conditions  or  not,  as  regards  their  surgical  re- 
lations from  the  standpoint  of  treatment?  The  ques- 
tion is  not,  whether  they  are  adventitious  as  claimed 
by  Otis,  or  normal  as  claimed  by  Weir,  but  what  is 
their  relations  to  the  morbid  state  of  the  canal  ? I 
claim  that  the  difference  between  the  two  conditions 
is  one  of  degree  and  not  of  kind,  and  I can  see  no  logic 
in  the  dispute  upon  either  side. 

From  what  has  been  said  I think  that  the  direct 
relation  of  stricture  to  the  severity  of  the  primary 
urethritis  may  be  clearly  seen. 

It  is  a self  evident  proposition  that  if  what  I have 
said  regarding  the  relation  of  stricture  to  friction 
be  true,  the  same  holds  good  with  relation  to  granu- 
lar, congested  and  eroded  patches  in  the  canal.  I 
believe,  moreover,  that  within  certain  limits  the  indi- 
cations for  treatment  may  be  the  same.  In  addition 
to  the  element  of  friction  in  producing  strictures  and 
other  lesions  of  the  urethra,  I acknowledge  the  impor- 
tance of  retained  infections  and  inflammatory  pro- 
ducts at  points  of  narrowing. 

M.  Desnos  has  recently  called  attention  to  what  he 
terms  slight  traumatisms  of  the  urethra  during  erec- 
tion, as  a cause  of  stricture.  In  my  lectures  for  ten 
years  past,  I have  claimed  that  slight  injuries  of  the 
mucous  membrane  and  perhaps  of  the  corpus  spon- 
giosum, frequently  result  during  urethritis,  as  a 
result  of  erections  while  the  elasticity  of  the  spongy 
urethra  is  impaired  by  plastic  exudate.  These  in- 
juries are,  of  course,  most  likely  to  occur  if  chordee 
be  present,  or  if  intercourse  be  attempted;  but  maj' 
happen  when  neither  circumstance  prevails.  It  is  not 
necessary  to  “break  the  chordee”  to  produce  them. 
Whenever  any  appreciable  quantit}^  of  blood  appears 
in  a gonnorrhoeal  discharge,  such  minute  traumatisms 
may  be  inferred.  These  slight  injuries  often,  in  my 
opinion,  form  the  groundwork  for  future  stricture 
building. 

Relative  frequency  of  Stricture  in  the  various  portions 
of  the  canal. — No  one  who  has  not  given  this  subject 
special  stud}?  can  realize  the  difficult}'  of  forming  an 
accurate  estimate  of  the  relative  frequency  of  stric- 


197 


ture  in  the  various  parts  of  the  canal.  The  different 
standpoints  of  observation  give  widely  varying  results. 
Otis  and  Thompson  can  never  be  nearer  together 
than  they  are  to-day,  unless  both  should  accept  the 
same  standard  as  a criterion  of  stricture,  and  use  the 
same  methods  of  exploration  and  diagnosis.  The 
Weir  faction,  with  its  normal  points  of  contraction  in 
the  pendulous  urethra,  certainly  cannot  become  rec- 
onciled to  the  teachings  of  Otis.  I know  of  several 
excellent  men  with  whom  I have  conversed,  whose 
methods  of  reasoning  are  so  widely  apart  that  each 
stamps  the  otlier  as  an  ignoramus.  One  begs  the 
question  by  accepting  the  view  of  Otis  that  an  urethra 
should  take  a sound  of  a caliber  proportionate  to  the 
dimensions  of  the  penis,  and  the  other  entirely  over- 
looks the  question  at  issue,  by  the  assertion  that, 
“that  kind  of  strictures  can  be  found  in  healthy  men.” 
I once  related  a case  of  congenital  stricture  in  the  pen- 
dulous urethra  to  a prominent  surgeon  of  this  city,  and 
he  asserted  that  the  patient  could  not  possiby  have  a 
stricture,  if,  as  I said,  he  could  take  a thirteen  English 
sound.  I presume  that  there  are  many  in  the  pro- 
fession who  would  claim  that  a patient  who  can  take  a 
thirty  to  thirty-five  French  sound  has  no  stricture. 
Yet  a patient  may  take  a forty  French  sound  and  the 
case  still  demand  urethrotomy.  Number  thirty  may 
pass  smoothly  an  obstruction,  which  a number  fifteen 
bulb  will  easily  demonstrate. 

Believing,  as  I do,  that  any  point  of  contraction  or 
inelasticity  in  the  urethra,  in  the  presence  of  a path- 
ological condition  of  the  mucous  membrane  con- 
stitutes a stricture,  I can  unhesitatingly  assert  my 
firm  conviction  that  stricture  of  the  urethra  is  most 
frequent  in  the  pendulous  portion  of  the  canal.  If 
care  be  taken  to  exclude  the  element  of  deep  ure- 
thrismus — which  exclusion  is  not  as  easy  as  some 
authors  would  have  us  believe — the  proportion  is,  I 
think,  ten  to  one. 

That  great  variance  of  opinion  exists  upon  this 
point  is  well  known,  and  Bumstead  and  Taylor  long 
ago  called  attention  to  the  fact  that  there  could  be  no 
harmony  of  results  between  those  who  studied  the 
subject  upon  the  living  and  those  whose  estimates 
were  formed  entirely  upon  observations  of  the  cada- 


;er.  Folet,  in  ISSl,  called  attention  to  the  frequency 
of  fibrous  stricture  in  the  pendulous  urethra,  and  its 
comparative  rarity  in  the  bulbo  membranous  region. 
This  author  claimed  that  deep  obstruction  existed  in 
all  cases  of  stricture  of  the  spongy  portion,  but  that 
the  deep  structure  was  nearly  always  spasmodic  and 
secondary  to  the  trouble  in  the  anterior  portion  of  the 
canal.  In  1866,  Verneuil  coolly  appropriated  Folet’s 
thunder  and  expressed  essentially  the  same  views  and 
in  very  nearly  the  same  language.  Otis,  writing  at  a 
later  period,  while  not  so  radical  as  his  French  pre- 
decessors, has  promulgated  similar  views,  but  in  a 
much  more  comprehensive  and  thorough  manner. 
The  relation  of  urethrismms  to  reflex  irritation  more 
or  less  remote  as  shown  by  Otis,  is  one  of  our  most 
important  modern  contributions  to  the  literature  of 
genito  urinary  pathology,  and  is  decidedly  compli- 
mentary to  the  genius  of  American  surger}'. 

In  estimating  the  frequenc}'  with  which  deep  spas- 
modic stricture  complicates  obstruction  in  the  pendu- 
lous urethra,  an  important  source  of  fallacy  exists. 
While  a deep  stricture  may  be  demonstrated,  in  nearly 
if  not  all  cases,  by  instrumentation,  it  does  not  nec- 
essarily follow  that  such  deep  strictures  exist  at 
other  lines.  A tender  urethra  resents  a foreign  bod)' 
quite  as  vigorously  as  does  the  e\’e,  and  as  soon  as 
the  sound  touches  a tender  spot  or  sensitive  stricture 
— even  of  large  caliber — in  the  pendulous  urethra,  a 
pronounced  reflex  contraction  is  observable  through- 
out the  entire  canal,  which  is,  of  course,  most  pro- 
nounced in  the  deep  portion.  A spasm  of  the  pendu- 
lous portion  is  not  usually  regarded  as  of  importance; 
indeed,  some  surgeons  discredit  it  altogether.  I have 
found,  however,  that  the  spong)'  portion  often  con- 
tracts so  firmly  about  the  sound  that  it  is  felt  to  be 
firmly  grasped  during  withdrawal  all  along  the  canal. 
This  spasm  in  the  pendulous  urethra  is  of  great 
assistance  in  diagnosis,  as  it  serves  to  force  diseased 
portions  of  the  canal  down  in  front  of  the  shoulder  of 
bulbous  instruments  of  a caliber  much  smaller  than 
the  stricture  will  really  admit.  Thus  it  often  happens 
that  a good-sized  sound  will  pass  by  obstructions 
upon  which  quite  small  bulbs  will  catch. 

In  some  cases  deep  spasm  exists  more  or  less  con- 


199 


stantly;  but  I believe  that  in  most  of  these  cases  there 
is  an  actual  organic  change  at  the  site  of  the  spas- 
modic stricture ; this  may  be  true  o’-ganic  deposit,  an 
erosion,  or  a congested  and  granular  patch.  Under 
such  circumstances  it  is  often  very  difficult  to  deter- 
mine, even  approximately,  the  proportionate  relation 
of  spasm  to  organic  lesion.  Oftentimes  the  true  con- 
dition of  affairs  can  only  be  determined  by  subtract- 
ing the  sources  of  reflex  spasm  in  the  anterior  ure- 
thra by  urethrotomy. 

Reflex  Neuroses  frotn  Stricture. — The  remote  or 
direct  nervous  disturbances  incidental  to  stricture  of 
the  urethra  are  too  often  lost  sight  of  in  the  strictly 
mechanical  aspect  of  the  condition.  The  decidedly 
complex  relations  of  the  genito- urinary  apparatus  to 
the  sympathetic  nervous  system  should  receive  more 
attention  than  is  usually  accorded  them.  Our  obser- 
vations of  the  reflex  neuroses  from  genital  irritation 
in  children  are  a key  to  the  solution  of  many  prob- 
lems in  the  urethral  pathology  of  the  adult.  There 
is  a general  impression  that  a stricture  is  of  little  im- 
portance unless  it  produces  distinct  symptoms  of  uri- 
nary obstruction.  When,  however,  one  meets  with 
cases  of  vesical  atony,  incontinence  of  urine,  impo- 
tency,  neuralgia  of  the  cord  and  testes,  lumbo-hypo- 
gastric  and  lumbo-sacral  neuralgia,  profound  mental 
depression  and  other  neuroses  entirely  and  almost 
magically  relieved  by  urethrotomy  of  strictures  of 
large  caliber,  the  importance  of  this  question  is 
brought  before  him  in  a very  forcible  manner.  The 
relation  of  such  conditions  to  congenital  or  acquired 
stricture  at  or  near  the  meatus,  is  especially  marked. 
I might  relate  numerous  interesting  cases  of  this 
character,  did  time  permit.  I have  found  this  sub- 
ject alone,  extensive  enough  for  an  entire  paper, 
which  I have  now  in  preparation  for  the  meeting 
of  the  Southern  Surgical  Association  in  Novem- 
ber. 

Toxicamia  from  Stricture. — The  relation  of  stricture 
to  uraemia — so-called — is  not  a new  theme.  Some- 
thing might  be  said  regarding  the  relation  of  shock 
from  surgical  operations  upon  the  urethra  to  toxicae- 
mia  and  consequent  urethral  fever,  but  the  subject  is 
too  comprehensive  for  discussion  here. 


200 


The  relation  of  absorption  of  ptomaines  from  the 
site  of  the  lesion  in  stricture — or  from  behind  it — to 
the  general  results  of  stricture,  is  unquestionably  of 
great  importance.  The  rapidity  with  which  many 
constitutional  symptoms  disappear  after  cure  of  deep 
strictures,  is  thus  easily  explained.  Urethral  chill, 
following  instrumentation,  is  also  explicable  in  the 
same  way  in  some  cases. 

The  possibility  of  mixed  infection  miust  be  taken 
into  consideration.  The  cases  of  cystitis,  epididy- 
mitis, peri-urethral  phlegmon,  pyelo-nephritis  and 
other  special  phenomena  secondary  to  stricture,  are 
not  all  dependent  upon  direct  extension  of  inflamma- 
tion, but  are  probably  due  in  many  cases  to  secondary 
infection.  A recent  case  of  my  own  is  strongly  sug- 
gestive in  this  regard.  A patient  whom  I was  treating 
for  several  irritable  strictures  of  comparatively  large 
caliber,  developed  multiple  nephritic  and  perinephritic 
abscesses  during  the  course  of  the  treatment.  An 
interesting  point  was  the  fact  that  the  formation  of 
the  abscesses  was  heralded  by  great  increase  of  irrita- 
bility and  spasm  in  the  deep  urethra. 

The  point  which  I desire  to  urge  most  strongly  is 
the  apparent  fact  that  all  patients  with  serious  stric- 
tures— particularly  of  the  deep  urethra — suffer  from  a 
greater  or  less  degree  of  toxaemia,  and  that  many 
cases  develop  secondary  infections  of  one  kind  or 
another. 

That  the  passage  of  instruments  may  precipitate 
toxaemia  is  granted.  The  danger  is  enhanced  by  un- 
cleanliness, but  stiictly  aseptic  instruments  may  cause 
trouble.  It  is  a question,  however,  whether  any  instru- 
ment passed  through  a diseased  anterior  urethra,  can 
be  aseptic  by  the  time  it  reaches  the  deeper  portions 
of  the  canal.  It  is  my  firm  conviction  that  strictl}’ 
aseptic  surgery  of  the  urethra  would  demand  a flush- 
ing out  of  the  canal  prior  to  the  introduction  of  even 
an  ordinary  sound.  This  we  know,  is  not  ordinaril}"^ 
done,  nor  is  it  always  practicable.  We  are,  most  of  us, 
therefore,  committing  cardinal  sins  from  the  stand- 
point of  aseptic  surgerjq  as  a matter  of  routine. 

Treatfnent  of  Stricture. — The  treatment  of  stricture 
of  the  urethra  has  given  rise  to  more  contention  and 
more  radically  opposed  views  than  almost  any  surgi- 


201 


cal  disease  that  could  be  mentioned.  One  faction 
never  cuts,  another  always  cuts,  and  still  another 
causes  organic  stricture  to  fade  into  the  misty  past 
by  the  use  of  “electrolysis”  alone. 

As  is  usually  the  case  under  such  circumstances  of 
contention,  the  philosophical  surgeon  will  occupy  the 
middle  ground.  The  best  reply  that  can  be  made  to 
the  extravagant  claims  of  the  urethrotomist  and  the 
still  more  extravagant  claims  of  the  electrolytic 
crank,  is  that,  “there  are  strictures  and  strictures.” 
To  some  of  the  so-called  conservatists,  it  would  be 
foolish  to  reply — the  differentiation  of  strictures  is 
a matter  beyond  their  comprehension.  They  cling 
to  the  traditions  of  the  past  with  a fatuity  and  obtuse- 
ness which  an  axe  might  possibly  impress,  but  argu- 
ment, never.  There  is  a vast  difference  between 
judicious  conservatism  and  the  cowardice  and  ignor- 
ance that  often  masquerades  as  conservatism. 

It  will  be  impossible  for  me  to  discuss  the  subject 
of  treatment  in  a comprehensive  manner,  in  this 
paper,  but,  with  your  kind  indulgence,  I will  attempt 
to  present  a few  practical  points. 

Dilatation  of  Stricture.- — By  dilatation  we  mean 
gradual  and  intermittent  dilatation.  Continuous 
dilatation,  excepting  with  soft  instruments  as  a pre- 
liminary to  gradual  dilatation,  is  out  of  date. 

Selection  of  Cases. — I believe  that  every  soft  and 
tractable  stricture  should  be  treated  by  dilatation. 
Even  admitting  that  urethrotomy  is,  in  many  cases,  a 
radical  cure,  it  is  far  better,  in  my  opinion,  for  a man 
to  be  enslaved  to  the  sound  for  the  rest  of  his  days  if 
by  so  doing  he  can  avoid  the  dangers  of  an  operation 
and  at  the  same  time  receive  satisfactory  relief  from 
his  symptoms. 

The  majority  of  deep  strictures  will  yield  to  dilata- 
tion, especially  if  all  obstructions  and  points  of  fric- 
tion and  irritation  be  primarily  removed  from  the 
pendulous  portion  of  the  canal.  If  such  points  exist, 
attempts  at  dilatation  'of  the  deep  stricture  only 
makes  matters  worse. 

It  has  been  my  experience  that  strictures  of  the 
pendulous  urethra  are  rarely  soft  and  tractable.  They 
are  generally  irritable  and  resilient,  and  the  more 
they  are  stretched  the  worse  they  get,  and  the  more 


202 


irritable  the  deep  urethra — which  is  perhaps  free  from 
local  disease — becomes. 

It  is  possible  to  distinguish  on  the  first  examina- 
tion, as  a rule,  those  strictures  of  the  pendulous  por- 
tion which  are  likely  to  yield  to  dilatation.  These, 
unfortunately,  are  rare.  The  nearer  the  stricture  is 
to  the  meatus  the  less  likely  it  is  to  yield  to  dilata- 
tion. Points  of  relative  inelasticity  will  never  yield 
to  dilatation. 

Frequency  of  Dilatation. — My  experience  goes  to 
show  that  the  majority  of  surgeons  dilate  at  too  fre- 
quent intervals.  Here  is  a prime  necessity  for  the 
selection  of  cases.  Each  stricture  is  a law  unto  itself. 
Some  cases  yield  best  to  dilatation  every  third  day. 
I have  seen  cases  in  which  biweekly  operations  gave 
the  best  results.  Many  strictures  are  tortured  into  irri- 
tability and  resiliency.  A few  weeks’  rest  sometimes 
obviates  the  necessity  of  urethrotomy.  It  is  hardly 
necessary  to  repeat  the  old  maxim  that  gentleness  is 
the  key-note  of  success  in  the  treatment  by  dilatation. 

Urethrotomy. — Dilating  urethrotomy  is  the  opera- 
tion of  election  in  the  majority  of  strictures  of  the 
pendulous  urethra.  It  is  required  many  times  as  a 
preliminary  to  deep  dilatation.  It  is  absurd  to  at- 
tempt to  dilate  a deep  stricture  without  cutting  a 
narrow  meatus,  or  other  firm  bands  which  may  exist 
in  the  anterior  urethra.  Dilatation  to  be  effective 
must  be  carried  to  the  extreme  limit  of  distensibility 
of  the  urethra.  It  is  impossible  to  satisfactorilj'^  di- 
late a No.  35  bulbo-membranous  region  via  a No.  30 
meatus  or  pendulous  urethra. 

I have  already  called  attention  to  friction  as  an  im- 
portant factor  in  stricture  and  gleet.  A division  of 
the  inelastic  and  unyielding  point  is  usually  required 
for  a cure.  Oftentimes  an  obstruction  will  be  due 
to  a tender  patch  in  the  urethral  mucous  membrane. 
This  causes  reflex  contraction,  and,  as  a consequence, 
the  affected  spot  is  never  at  rest.  Urethrotoni}',  how- 
ever, affords  the  required  rest,  and  the  lesion  disap- 
pears. Congested  and  granular  plaques  sometimes 
require  the  same  treatment,  and  for  similar  reasons ; 
there  is,  in  addition,  the  indication  for  an  alteration 
of  nutrition  at  the  diseased  point. 

Urethrotomy  should  always  be  performed  under 


203 


strict  antiseptic  precautions.  Instruments  require  as 
careful  boiling  as  in  the  performance  of  a laparotomy. 
The  urethra  should  be  flushed  out  with  a 1 in  2,000 
bichloride  solution  as  a preliminary  measure. 

Dangers  of  Urethrotomy. — In  spite  of  the  optimistic 
views  of  those  who  operate  as  a matter  of  routine, 
urethrotomy  is  attended  by  some  inconveniences,  and 
possible  dangers.  I acknowledge  this  frankly,  and, 
although  in  an  extensive  experience  I have  had  no 
fatalities,  I confess  to  several  scares. 

I find  that  the  general  practitioner  has  less  respect 
for  the  dignity  of  the  operation  than  some  specialists. 
It  is  quite  common  for  the  surgeon  to  operate  on 
stricture  at  his  office  and  let  the  patient  go  about  as 
if  nothing  had  happened,  or,  at  most,  with  two  or 
three  days’  confinement  to  the  house.  My  opinion  is 
that  a urethrotomy  properly  performed  is  a major 
operation,  necessitating  a week’s  rest  at  least  in  the 
majority  of  cases.  Haemorrhage  is  an  ever  present 
danger. 

Interference  with  erection  and  cuivature  of  the 
penis  are  occasional  results.  I have  seen  no  perma- 
nent damage  of  this  character;  but  I think  it  occurs 
more  often  than  is  acknowledged  by  most  operators. 
One  case  of  my  own  had  a double  twist  in  the  organ 
at  the  end  of  a year  ; but  as  he  had  had  two  opera- 
tions and  contracted  gonorrhoea  a month  after  the 
first  one,  and  was  continually  drunk,  his  case  was 
hardly  a fair  criterion. 

Sepsis  is  usually  avoidable  by  drawing  off  the 
urine  with  a soft  catheter,  and  flushing  the  canal  for 
a few  days  after  operation. 

Internal  dilating  urethrotomy  is  most  applicable  to 
the  pendulous  urethra.  My  friend.  Dr.  Edw.  W. 
Palmer,  of  Louisville,  has  reported  a series  of  cases 
of  favorable  results  from  deep  internal  section.  I 
have  followed  him  with  half  a dozen  similar  cases. 
In  general,  however,  it  is  my  opinion  that  at  present 
external  section  is  safest  where  any  cutting  operation 
is  necessary  in  the  deep  urethra.  A guide  can  usually 
be  introduced,  and  the  operation  is  then  a compara- 
tively safe  one.  Once  in  a great  while  a case  will  be 
met  with  in  which  a guide  cannot  be  introduced,  as 
in  a recent  case  in  which  I performed  the  Wheelhouse 


2o4 


operation,  and  found  a good-sized  calculus  behind 
the  stricture. 

The  rule  that  traumatic  strictures  and  all  strictures 
complicated  by  extensive  perineal  induration  and 
fistulas  require  perineal  section,  is  a good  one  to  fol- 
low. The  same  is  true  of  cases  in  which  dilatation 
is  productive  of  sepsis  and  chill.  I have  found  in 
several  of  these  cases,  however,  that  the  internal  use 
of  the  oil  of  eucalyptus  seemed  to  be  an  excellent 
prophylactic  of  chill  and  febrile  reaction.  Much 
more  might  be  said  upon  the  subject  of  urethrotom)', 
but  time  does  not  permit. 

Divulsion  of  Stricture. — This  operation,  formerly 
so  popular,  is  falling  into  desuetude  among  pro- 
gressive American  surgeons.  Within  certain  limita- 
tions, however,  it  is  still  a useful  method  to  fall  back 
upon.  It  would  seem  that  it  ought  to  be  the  opera- 
tion of  necessity  rather  than  election.  In  cases  where 
time  is  an  important  consideration,  divulsion  is  justi- 
fiable in  strictures  of  the  deep  urethra;  rarely,  if 
ever,  in  those  of  the  pendulous  portion.  In  resilient 
strictures  of  large  caliber,  divulsion  is  usually  im- 
practicable. 

Electrolysis. — He  would  be  wise,  indeed,  who  could 
determine  the  truth  regarding  the  use  of  electricity 
in  urethral  stricture  from  the  reported  results  which 
have  appeared  in  medical  literature.  The  changes 
have  been  rung  by  observers  of  widelj"  different  char- 
acters and  degrees  of  credibility.  The  electrolytic 
monomaniac,  the  commercial  electrician,  the  intol- 
erant bigot,  and  the  man  who  recognizes  no  differ- 
ence between  the  galvanic  and  faradic  currents,  have 
all  been  heard  from,  with  the  result  that  many  con- 
scientious surgeons  have  thrown  their  bulbs  and  bat- 
teries into  the  dead-lumber  room.  It  is  eas)'  to 
understand  how  Newman,  the  hobbyist,  can  claim  so 
much  for  the  electrolysis  of  stricture;  it  is  not  so  easy 
to  understand  the  absolute  condemnation  of  the 
method  by  so  broad  and  scientific  a man  as  Keyes. 

To  claim  such  extravagant  results  as  does  the 
Newman  school  is  no  more  absurd  than  to  assert  that 
the  method  is  absolutely  valueless.  We  must  recog- 
nize the  fact  that  the  galvanic  current  exerts  definite 
physiological  effects  upon  living  tissue,  health)’  or 


205 


morbid.  Knowing  these  effects,  and  knov^^ing  the 
conditions  present  in  stricture,  no  fair-minded  man 
can  deny  the  probability  of  definite  results  in  practice. 
The  term  electrolysis  is  here,  it  seems  to  me,  a very 
unfortunate  one.  The  method  should  be  termed 
galvanism. 

I do  not  consider  it  practicable,  within  the  limits 
of  safety,  to  bring  the  electrolytic  action  of  the  gal- 
vanic current  to  bear  upon  a urethral  stricture,  with 
the  possible  exception  of  flaps  and  bands  which  are 
ingrafted  upon  the  stricture  per  se. 

We  have  in  organic  stricture  several  factors 

1.  The  first  and  most  important  is  a new  growth 
of  fibro-connective  tissue. 

2.  Young  cells  in  the  process  of  metamorphosis 
into  fixed  connective  tissue. 

3.  More  or  less  oedematous  infiltration. 

4.  Hyperagmia  or  congestion. 

5.  Spasm. 

6.  Flaps,  bands,  and  bridles,  due  to  exudate 
within  the  lumen  of  the  canal  and  binding  its  folds 
together.  These  are  often  traumatic,  and  due  to 
clumsy  instrumentation. 

Of  the  conditions  named,  only  the  first  is  essential 
to  stricture.  The  other  factors  I will  term  plus  con- 
ditions of  stricture.  These  plus  conditions  are  vari- 
able in  amount  and  frequency,  but  may  all  be  present 
in  any  given  case,  and  may  be  either  transitory  or 
permanent. 

When  properly  used,  the  galvanic  current  stimu- 
lates the  circulation,  stimulates  the  absorbents,  and 
allays  irritation  and  spasm.  In  addition  we  have  the 
mechanical  effect  of  the  bulb  of  the  electrode. 

To  put  the  case  concisely,  I will  state  my  belief 
that  galvanism,  judiciously  used,  will  often  subtract 
the  plus  conditions  of  stricture  and  facilitate  the 
penetration  of  otherwise  surgically  - impermeable 
stricture.  Once  these  conditions  are  removed,  elec- 
tricity is  no  longer  useful,  and  we  must  seek  other 
means  of  relief.  It  may  thus  be  seen  that  if  these 
statements  are  true,  the  range  of  application  of  elec- 
tricity is  not  wide.  I do  not  believe  it  is  ever  cura- 
tive of  organic  stricture,  nor  do  I believe  it  is  often 
of  value  in  the  pendulous  urethra.  Strictures  of  this 


2o6 


portion  of  the  canal  are  very  likely  to  require  ure- 
throtomy; certain  it  is,  to  my  mind,  that  electricity  will 
rarely  obviate  the  necessity  for  the  operation.  A 
case  of  deep  stricture  occasionally  arises  where  elec- 
tricity will  relie.ve  retention,  and  so  facilitate  sub- 
sequent dilatation  as  to  be  invaluable,  but  such  cases 
are  not  frequent.  Surgeons  may  report  cases  of  im- 
permeable stricture  in  which  electricity  succeeded, 
after  all  else  had  failed,  by  the  dozen;  but  there  will 
still  be  those  among  us  who  believe  that  the  man 
who  sees  so  many  impermeable  contractions  is  either 
a paper  surgeon,  unworthy  of  belief,  or  his  reported 
cases  are  simply  impermeable  to  him.  Impermea- 
bility of  stricture  upon  one  end  of  the  bougie  some- 
times means  impermeability  of  brain  upon  the  other. 

In  thus  stating  what  I believe  to  be  the  merits  of 
the  “ electrolytic,”  or,  more  properly,  the  galvanic 
treatment  of  stricture,  I have  endeavored  to  present 
them  fairly  and  without  bias. 


LECTURES  ON  THE  TREATMENT  OF 
SYPHILIS.* 


Lecture  I. 


Treatment  of  Syphilis. — Simplicity  of  local  treatment  of  chancre, — 
Avoidance  of  caustics  and  ointments. — Excision  of  chancre. — Advan- 
tages of  excision. — Supposed  antidotal  effect  of  mercury  in  syphilis. — 
Proper  method  of  using.  Power  of  mercury  to  induce  fatty  degenera- 
tion and  elimination  of  morbid  material. — Uniformity  of  all  success- 
ful methods  of  treatment,  in  producing  fatty  degeneration.— Cleven- 
ger’s theory  of  the  mechanical  action  of  mercury. — Probability  of 
mercury  entering  the  system  in  both  mechanical  and  chemical  con- 
ditions. —Action  of  mercury  upon  the  blood. — Action  varies  widely 
under  different  conditions. — Action  of  iodine  in  syphilis. — When  to 
begin  the  use  of  mercury, — Form  of  mercurial  to  be  selected.— Im- 
portance of  protracted  treatment. — Mercury  by  inunction  and  fumi- 
gation.— Local  use  of  mercurials. — Mercury  by  hypodermic  injections. 

Gentlemen: — We  now  come  to  that  portion  of  our 
course,  which  you  no  doubt  are  much  more  anxious  to 
study  than  the  more  abstruse  and  to  you,  perhaps, 
less  practical  topic  of  the  pathology  of  syphilis. 
Remember  that  there  is  an  absolute  necessity  for  a 
good  idea  of  the  pathology  of  the  disease  in  order  that 
you  may  understand  the  rationale  of  its  therapeutics. 

We  have  studied  the  treatment  of  the  primary  sore 
in  connection  with  the  description  of  its  pathological 
characters,  but  there  are  some  points  which  will  bear 
repetition,  and  others  to  which  I have  not  yet  alluded, 
but  which  appear  to  me  very  important.  In  the  first 
place,  do  not  forget  that  the  chancre  is  to  be  coaxed, 
not  driven,  and  that  it  will  cause  little  annoyance  if 
you  give  it  half  a chance.  Use  the  black  or  yellow 
wash,  calomel  or  iodoform  powder,  or  even  simple 
absorbent  cotton  as  a dressing,  and  let  the  induration 
take  care  of  itself.  If  you  wish  to  see  by  contrast 
the  results  of  meddlesome  officiousness,  try  rubbing 
a hard  chancre  with  nitrate  of  silver,  and  then  apply 
some  nasty,  greasy  ointment.  You  will  have  a fine 

♦Delivered  at  the  Chicago  College  of  Physicians  and  Surgeons- 
Reported  by  William  Whitford. 


2o8 


mess  of  it,  and  a condition  of  affairs  which  I often  see 
in  patients  who  have  been  treated  in  this  manner,  by 
physicians,  drug  clerks,  or  very  often  by  themselves. 
Avoid  grease  and  nitrate  of  silver,  as  an  abomination, 
if  you  would  not  lose  your  patients’  confidence.  If, 
as  in  the  case  of  a mixed  sore,  it  becomes  necessary 
to  cauterize,  use  a caustic,  and  have  done  with  it,  and 
not  an  irritant  like  nitrate  of  silver,  which  sears  but 
does  not  destroy.  Apply  carbolic  acid  followed  by 
the  fuming  nitric,  or  better  still,  use  pure  bromine  or 
the  actual  cautery.  The  form  of  caustic  is  not  so  im- 
portant as  the  manner  of  its  use.  Select  your  caustic 
early  in  practice,  and  stick  to  it  until  you  know  how 
to  use  it.  As  a last  injunction  instruct  your  patient 
in  the  matter  of  rest.  Let  him  rest  the  affected  mem- 
ber by  avoidance  of  sexuality  in  thought  or  action,  b}'^ 
taking  very  little  exercise,  and  no  stimulants,  and 
lastly  by  handling  it  as  little  as  possible.  The  oftener 
he  examines  himself  to  note  the  progress  of  the  case, 
the  worse  he  will  eventually  be.  Occasionally  a 
chancre  will  become  phagedenic,  in  which  event  special 
measures  of  treatment  become  necessary,  as  seen  in 
connection  with  phagedaenic  chancroid.  Free  stimu- 
lation and  local  cauterization  with  the  actual  cauter}', 
followed  by  strict  antisepsis,  are  the  principal  indica- 
tions. Tonics  and  opium  must  be  given.  Opium  was 
specially  endorsed  by  Ricord  in  phagedaenic  chancre. 
The  late  Dr.  F.  B.  Norcom,  of  Chicago — my  lamented 
preceptor — used  to  obtain  excellent  results  from  the 
same  remedy.  I have  given  it  for  the  relief  of  pain 
and  nervous  irritation  in  such  cases,  but  have  as  }'et 
arrived  at  no  definite  conclusion  in  regard  to  its  pos- 
sible specific  effect. 

There  is  one  radical  method  of  dealing  with  the 
chancre,  which  I commend  to  }’our  attention,  and 
which  is  often  a wise  thing  to  do.  I refer  to  the  treat- 
ment by  excision.  It  is  claimed  by  some  advocates 
of  this- method  that  by  it  the  general  symptoms  are 
modified  and  in  some  instances  prevented  entirely, 
not  even  the  indolent  glandular  changes  being  per- 


— 2og  — • 


ceptible.  Theoretrcally,  if  the  views  of  the  path- 
ology of  the  disease  which  I have  called  to  your 
attention,  be  correct,  excision  of  the  initial  induration 
ought  to  prevent  general  infection  completely,  but 
unfortunately  this  has  as  yet  to  be  proven  to  be  the 
case  in  actual  practice.  As  for  myself,  I am  perform- 
ing excision  whenever  the  patient  will  consent,  and 
am  trying  to  arrive  at  a definite  conclusion  in  regard 
to  the  matter  from  actual  observation.  I have  already 
studied  some  thirty  cases  in  this  way,  and  have  become 
pretty  thoroughly  convinced  that  the  operation  is  of 
benefit.  I have  not  yet  omitted  the  administration  of 
mercury,  but  am  inclined  to  believe  that  excision  fol- 
lowed by  the  exhibition  of  the  drug  is  productive  of 
better  results  on  the  whole  than  the  treatment  by 
mercury  alone.  In  excising  a chancre  be  careful  to 
do  so  only  after  the  induration  is  ripe,  so  to  speak, 
i.  e. , after  it  has  come  to  a standstill.  Otherwise, 
induration  is  likely  to  recur  in  the  cut  edges. 

There  are  several  considerations  which  may  be 
advanced,  and  which  are  in  the  main  endorsed  by 
Otis,  in  favor  of  the  operation,  in  which  nearly  all 
will  agree,  viz. : We  thereby  remove  a constant 

focus  of  infection,  which  is  present  as  long  as  the  in- 
duration persists.  2d.  We  at  once  remove  a large 
mass  of  syphilized  cells  which  would  otherwise  only 
be  removed  by  the  slower  process  of  fatty  degenera- 
tion, absorption  and  elimination.'  3d.  We  obviate 
the  possibility  of  the  transmission  of  the  disease  to 
others  by  means  of  the  initial  lesion,  a point  of  great 
importance  to  married  persons.  4th.  We  lessen  the 
danger  of  suppurating  bubo,  in  case  the  chancre 
should  inflame.  5th.  We  remove  a constant  source 
of  irritation,  and  lessen  the  danger  of  phagedsena  and 
inflammation  which  might  disable  the  patient.  6th. 
The  patient  is  able  to  resume  his  marital  relations  at 
once,  after  the  incision  has  cicatrized  perfectly.  Why 
it  is  that  we  cannot  prevent  constitutional  syphilis,  by 
excision  of  the  chancre  prior  to  local  glandular 
changes,  is  not  clearly  explicable,  if  we  accept  the 


210 


View  that  the  disease  is  practically  local  primarily. 
It  is  probable  that  a morbid  impression  has  been 
made  upon  the  tissues  by  the  syphilitic  poison,  which 
began  the  moment  infection  occurred,  and  which  has 
extended  far  beyond  the  limits  of  the  initial  lesion 
before  its  appearance.  Excision  of  the  chancre 
should  be  preceded  by  washing  the  parts  in  a solution 
of  bichloride  of  mercury  i-iooo.  The  ulceration,  if 
any  exist,  should  then  be  cauterized  and  dusted  with 
calomel.  The  chancre  should  now  be  transfixed  with 
a tenaculum,  raised  from'  its  bed,  and  the  mass  of  in- 
duration quickly  removed  with  a sharp  scalpel  or 
curved  scissors.  The  parts  should  be  sutured  with 
fine  catgut  or  silk,  and  the  parts  kept  at  rest  for  a 
few  days  with  cold  water  dressings.  Within  forty- 
eight  hours,  as  a rule,  the  wound  will  have  united  and 
the  stitches  may  be  removed.  In  a few  days,  if  no 
lesion  be  present,  the  patient  may  resume  his  marital 
relations. 

The  constitutional  treatment  of  syphilis  is  naturall}’ 
a subject  of  paramount  importance.  Errors  more 
serious  in  their  effects  than  the  disease  itself  are  often 
committed  by  those  whose  practice  is  not  founded 
upon  a sound  pathological  basis.  The  disease  has 
long  been  treated  upon  the  principle  that  there  is 
present  a constitutional  poison,  which  must  be  anti- 
doted, and  mercury  has  appeared  to  be  the  antidote. 
Hutchinson  has  taught  that  this  drug  has  the  prop- 
erty of  neutralizing  the  specific  virus  upon  which 
syphilis  is  supposed  to  depend.  This  theor}'  of  the 
antidotal  effect  of  mercury  has  been  accepted  by  some 
of  our  best  syphilographers.  They,  however,  in  thus 
accepting  the  antidotal  doctrine,  have  seemed  to  con- 
sider it  all-sufficient,  and  have  failed  to  explain  the 
physiological  action  of  the  drug,  and  have  given  it 
solely  because  experience  has  proven  that  it  is  cura- 
tive in  syphilis.  Now,  we  find  that  even  when  the 
system  has  been  completely  saturated  with  mercur}’, 
even  to  the  extent  of  producing  severe  ptyalism,  the 
disease  returns  directly  the  drug  is  withdrawn,  thus 


211 


showing  that  the  syphilis  has  in  no  sense  been  anti- 
doted. On  the  contrary,  the  case  is  usually  worse 
than  ever.  O/i  the  other  hand,  we  find  that  the  slow, 
continiwiis  and  moderate  use  of  mercury , for  a period  cor- 
responding to  the  maximum  time  of  the  normal  duration 
of  the  disease  as  nearly  as  may  be,  and  without  at  any 
time  producing  its  full  physiological  efilects,  will  bring 
about  a cure,  which  can  be  accomplished  in  no  other  way. 

It  is  well  known  that  mercury  has  the  power  of  in- 
ducing fatty  degeneration  and  elimination  of  inflam- 
matory products,  or  in  other  words,  “of  relieving 
tissues  encumbered  with  superfluous  and  obstructive 
material.”  This  condition  of  the  tissues  is  precisely 
what  we  have  in  syphilis,  and  as  mercury  is  the  best 
remedy  we  have  for  such  a pathological  state,  irre- 
spective of  causation,  we  administer  it  throughout  the 
natural  course  of  the  disease,  not  to  antidote  a poison, 
but  to  remove  the  morbid  results  produced  by  it,  as  fast  as 
they  are  formed,  until  finally  the  syphilitic  impression 
upon  the  organism  has  naturally  exhausted  itself.  We 
have  already  seen  that  the*  “virus”  of  syphilis  is  not 
a material  substance,  but  practically  consists  in  an 
influence  which  a degraded  cell  has  over  another 
which  is  health}^,  causing  rapid  proliferation  and 
obstructive  accumulation  of  the  cells  so  influenced. 
It  is  a rather  peculiar  fact,  that  every  method  of  treat- 
ment for  syphilis  that  has  been  advocated  for  the  last 
two  or  three  centuries  has  comprised  such  measures 
as  tend  to  produce  rapid  tissue  change.  The  sweat- 
ing cure,  the  use  of  hot  baths  as  at  the  Hot  Springs 
of  Arkansas,  the  purgation  and  starvation  cures, 
Boeck’s  method  of  syphilization,  and  the  treatment  by 
pustulation  with  tarter  emetic,  all  of  which  have  been 
recommended  by  various  authorities  at  different  times, 
are  chiefly  active  through  their  power  of  inducing 
fatty  changes  in  the  tissues. 

The  action  of  mercury  upon  the  system  has  been 
the  subject  of  considerable  controversy,  particularly 
as  regards  the  form  in  which  it  enters  the  blood.  /_ 
very  ingenious  theory  was  promulgated  a few  years 


212  — 


ago  by  Prof.  S.  V.  Clevenger,  of  Chicago.  This  gen- 
tleman has  endeavored  to  show  that  mercury  does  not 
enter  the  system  as  a chemical  compound,  but  as 
metallic  mercury  in  an  exceedingly  fine  state  of  subdi- 
vision, and  that  it  acts  upon  disease — particularly 
syphilis — in  a purely  mechanical  manner,  by  pushing 
the  syphilized  cells  through  the  fine  capillaries,  and 
eventually  into  the  various  eliminative  areas  of  the 
body,  from  which  they  are  removed  as  is  other 
excrementitious  matter. 

Clevenger  has  found  by  examination  of  the  tissues 
after  the  use  of  mercury  by  inunction,  that  they  are 
filled  with  minute  globules  of  the  metal,  thus  showing 
that  it  does,  in  that  instance  at  least,  enter  the  blood 
in  a state  of  fine  subdivision.  Another  argument  is 
the  fact  that  free  mercury  is  to  be  found  in  the  tissues 
of  patients  who  have  been  taking  the  drug  for 
some  time. 

The  prevailing  view  has  been  that  mercury  enters 
the  system  as  a chemical  compound,  and  brings  about 
an  antidotal  effect,  or  produces  a fatty  metamorphosis 
of  the  diseased  cells. 

My  own  idea  is  that  mercury  may  enter  the  blood 
in  either  form.  When  it  enters  as  a chemical  com- 
pound, it  ma}'  split  up  so  as  to  liberate  a certain 
amount  of  the  pure  metal,  or  entering  as  metallic 
mercury  it  may  undergo  chemical  changes  in  the 
tissues,  these  effects  varying  in  different  cases.  Cer- 
tain it  is  that  finely  subdivided  mercur}'^  introduced 
into  the  great  physiological  chemical  laboratory  of  the 
body  is  quite  likel}^  to  undergo  chemical  changes. 
Should  it  be  demonstrated  that  mercury  cannot  exist 
in  the  body  as  a chemical  compound,  and  that  it  can- 
not act  in  any  but  a mechanical  manner,  I should 
still  be  inclined  to  doubt  its  alleged  ferret-like  prop- 
erties of  chasing  and  pushing  the  diseased  cells  out  of 
the  back  doors  and  chimne\'s  of  the  econoni}’,  and 
should  be  inclined  to  believe  that  it  acted  by  blocking 
up  the  vessels  leading  to  the  s}'philitic  neoplasia,  and 
thus  enhancing  their  own  intrinsic  tendency  to  fatty 


— 213- 


degeneration.  Practically,  I am  firmly  convinced 
that  the  drug  acts  by  inducing  fatty  degeneration,  but 
whether  by  a mechanical  or  chemical  action,  or  by  a 
combination  of  both — which  is  highly  probable — does 
not  seem  to  be  of  any  great  moment. 

The  action  of  mercury  upon  the  blood  is  of  great 
practical  interest,  inasmuch  as  by  its  use  two  diam- 
etrically opposite  effects  may  be  produced,  according 
to : ist.  The  dose  used;  ad.  The  duration  of  its 

administration;  3d.  The  constitutional  condition  of 
the  patient;  and  4th,  the  stage  of  the  disease.  If  the 
drug  be  given  in  full  doses  for  a few  days,  or  in  fre- 
quently repeated  small  doses  for  twenty-four  to  thirty- 
six  hours,  severe  stomatitis  and  ptyalism  may  be  pro- 
duced. If  it  be  given  in  a less  vigorous  fashion  for  a 
longer  period,  we  may  have  pallor  and  debility,  due 
to  a depreciation  in  the  quantity  and  quality  of  the 
red  blood  corpuscles,  to  defibrination  of  the  blood 
plasma  and  increased  tissue  waste.  A certain  degree 
of  these  effects  is  necessary  in  the  treatment  of 
syphilis,  but  it  is  our  chief  aim  to  keep  them  within 
bounds,  and  to  avoid  the  danger  of  producing  perma- 
nently injurious  effects.  Such  effects  as  great  pallor, 
wasting  and  debility,  pustular  or  vesicular  eruptions 
with  fever  known  as  the  “mercurial  fever,”  and 
marked  tremors,  may  result  from  the  action  of  mer- 
cury, and  that,  too,  without  the  occurrence  of 
ptyalism.  On  the  other  hand,  jmall  doses  of  mer- 
cury, in  various  cachectic  or  anaemic  conditions, 
particularly  during  the  sequelae  of  syphilis,  will 
rapidly  and  markedly  increase  the  quantity  and  im- 
prove the  quality  of  the  red  corpuscles  and  fibrine. 
thus  lessening  h}'dr^mia.  This  statement  is  based 
upon  the  experiments  of  Prof.  Ke}'es  with  the 
haematometer,  and,  moreover,  upon  personal  obser- 
vation of  the  action  of  the  drug.  The  question  of  the 
possible  accumulation  and  prolonged  retention  of 
mercury  in  the  system  is  as  yet  subjudice,  the  weight 
of  evidence  being  apparently  in  favor  of  the  view  that 
proofs  of  such  a result  of  the  drug  are  wanting.  I 


214 


1 73  not  yet  seen  any  of  those  cases  in  which  portions 

. bone  are  found  to  be  “full  of  metallic  mercury.” 
t hat  metallic  mercury  may  be  found  in  the  tissues 
during  a prolonged  and  thorough  course  of  mercury 
is  true,  but  that  such  a condition  prevails  for  years 
after  the  treatment,  I most  emphatically  do  not  be- 
lieve. Alleged  cases  of  this  character  have  probably 
been  under  more  recent  mercurial  treatment  than 
they  acknowledge  or  than  they  are  aware.  The)' 
may  have  been  innocentl)'  taking  medicines  of  mer- 
curial composition. 

In  a series  of  elaborate  experiments  by  Dr.  Schus- 
ter, of  Aix-la-Chapelle,  has  shown  that  the  elimination 
of  mercury  by  the  faeces  is  by  no  means  inconsiderable.  * 
The  method  of  administration  was  by  inunction.  Some 
of  this  eminent  authority’s  conclusions  are  of  interest. 
He  concludes  : 

“I.  That  elimination  of  mercury  by  the  faeces  is 
regular  and  continuous. 

“ 2.  That  elimination  after  thirty  to  forty-five  days 
of  mercurial  inunction  is  complete  in  six  months. 

“That,  consequently,  persistence  of  mercur}'  in  the 
organism  cannot  occur. 

“This  conclusion  is  important  as  bearing  upon  the 
cumulative  action  of  mercury.” 

There  is  another  remedy  which  experience  has 
shown  to  be  curative  in  syphilis,  and  which  is  second 
only  to  mercury.  I refer  to  iodine,  which  in  the 
form  of  the  iodides  is  exceedingly  useful,  especially  in 
late  syphilis.  The  iodides — of  which  potassic  iodide 
is  the  type — act  in  two  ways  in  the  cure  of  st'philis  : 
viz.,  first,  by  their  own  intrinsic  power  of  producing 
fatty  degeneration,  and  elimination  of  morbid  prod- 
ucts ; and  second,  by  liberating  and  exciting  to 
renewed  activity  the  mercury  which  ma)'  be  stored  up 
in  the  tissues,  thus  assisting  its  action.  It  is  evident 
that  the  first  of  these  effects  is  the  most  important, 
for  the  iodides  have  a most  powerful  effect  in  resolv- 
ing the  products  of  inflammatory  changes,  or  of 


* Journal  of  Cutaneous  anil  Venereal  Diseases,  Sept.,  1883. 


— 215  — 


adventitious  deposits,  irrespective  of  their  cause.  I 
make  this  assertion  in  the  face  of  the  argument  that 
iodine  can  cure  syphilis  only  by  liberating  mercury 
from  the  tissues,  and  that  it  is  the  mercury  and  not 
the  iodides  that  produces  the  curative  effects.  That 
this  is  incorrect  is  shown  by  the  beneficial  effects  of 
iodide  of  potassium  in  cases  of  late  syphilis  in  which 
mercury  has  never  been  administered.  * 

Having  decided  upon  the  administration  of  mercury 
in  the  constitutional  management  of  syphilis,  when 
shall  we  begin  its  use  ? It  is  claimed  by  some  that 
it  is  not  good  practice  to  begin  treatment  until  the 
secondary  symptoms  develop,  until,  in  short,  the  case 
is  matured,  as  mercury  will  have  little  effect  prior  to 
that  time.  Now  I believe  that  it  is  our  duty  to  begin 
treatment  just  as  soon  as  we  are  positive  of  the 
diagnosis,  as  we  thereby  shorten  the  duration  of  the 
initial  lesion,  and  modify  or  even  prevent  secondary 
symptoms.  To  save  the  patient  from  lesions  upon 
the  body  or  face,  which  “he  who  runs  may  read,”  is 
very’^  desirable,  and  is  only  to  be  accomplished  by 
early  treatment.  It  must  be  acknowledged,  however, 
that  those  cases  in  which  treatment  is  not  begun  until 
pronounced  eruptions  appear,  sometimes  seem  to  re- 
spond more  readily  to  therapeutic  measures,  and  to 
give  rather  less  annoyance  during  the  active  period 
than  those  in  which  mercury  is  given  as  soon  as  the 
chancre  develops.  Whether  the  prospect  of  a perma- 
nent cure  is  brighter,  is  questionable.  Under  the 
caption  “When  to  begin  the  treatment  of  Syphilis  ?” 
my  friend  Dr.  Dumesnil,  in  the  St.  Louis  Medical 
Journal  for  August,  1885,  opposed  very  strongly  the 
practice  of  giving  mercurials  before  secondary  erup- 
tions appear,  no  matter  how  plainly  marked  the  case. 
The  difficulty  of  diagnosis  is  one  of  the  most  powerful 
arguments  advanced,  and  is  presented  so  clearly  and 
forcibly  that  one  can  hardly  offer  a criticism.  There 
are,  however,  some  cases  which  are  so  plainly  marked 

* In  the  British  and  Foreign  Medical  Review  for  Oct.,  184.5,  Hassing 
of  Copenhagen,  reported  19.5  eases  of  syphilis,  70  of  which  were  cured 
by  the  iodide  of  potassium  alone,  without  mercury  at  any  stage. 


• — 2i6  — • 


that  this  argument  falls  to  the  ground.  In  quite  a 
proportion  of  cases  the  conscientious  physician  must 
necessarily  wait,  and  regarding  such  dubious  cases 
there  should  be  no  difference  of  opinion.  Dr.  Dumes- 
nil  further  claims  that  by  the  administration  of  mer- 
cury secondary  symptoms  are  not  prevented,  they  are 
merely  delayed.  Now  this  statement  is  rather  too 
comprehensive.  It  is  true  that  secondary  symptoms 
are  rarely  prevented  entirely,  but  afe  they  not  usual!}' 
markedly  modified  ? What  is  to  be  said,  moreover, 
in  regard  to  those  cases  in  which  no  symptoms  what- 
ever follow  the  primary  sore  until,  perhaps  years  after 
the  disease  was  forgotten,  severe  sequelae  appear. 
According  to  Dumesnil,  the  non-appearance  of  sec- 
ondary symptoms  would  indicate  that  in  such  cases 
syphilis  did  not  exist.  In  some  cases  secondary 
symptoms  are  very  slight,  and  apt  to  be  overlooked 
by  the  patient.  In  such  cases  the  necessity  for  con- 
stitutional treatment  might  be  first  announced  by 
severe  sequelae  at  a period  too  late  to  hope  for  a 
permanent  cure.  I think  from  personal  experience 
that  in  doubtful  cases  delay,  as  suggested  by  Fourn- 
ier, is  most  proper,  but,  on  the  other  hand,  that 
whenever  an  unequivocal  diagnosis  can  be  made, 
treatment  should  be  begun  at  once. 

Having  determined  upon  the  administration  of 
mercury,  it  remains  to  select  an  eligible  preparation. 
The  mildest  ajid  least  irritating  form  of  the  drug,  is 
the  protiodide,  or  as  it  is  sometimes  termed,  the 
green  iodide.  It  is  best  given  in  pill  form,  in  doses 
of  one  the  average,  one-fifth  of  a grain,  thrice  daily. 
This  dose  is  to  be  continued  for  several  days,  and 
then  increased  one  pill  per  day  until  the  gums  be- 
come somewhat  tender,  or  the  stomach  and  bowels 
are  disturbed.  I generally  give  the  drug  until  the 
gums  are  slightly  effected,  and  then  gradually  lessen 
the  dose  until  the  patient  is  taking  about  half  the 
amount  necessary  to  produce  slight  physiological 
effects.  This,  as  Dr.  Keyes  terms  it,  is  the  patient's 
average  dose,  and  is  usually  from  two  to  four  pills  of 


— 2i7  — 


the  strength  mentioned,  daily.  It  is  generally  con- 
tinued throughout  the  course  of  treatment.  It  is 
well  to  bear  in  mind  the  possibility  of  injurious  effects 
from  the  cumulative  action  of  the  drug,  and  also  the 
fact  that  it  is  apt  to  less  its  effect  upon  the  disease 
after  a time.  A good  plan  is  to  omit  the  protiodide 
at  intervals  of  two  or  three  months,  and  give  potassic 
iodide  pretty  freely  for  about  four  weeks.  In  this 
way  any  mercury  which  may  be  stored  up  in  the  tis- 
sues, is  liberated,  rendered  active  and  eliminated,  and 
the  system  again  rendered  susceptible  to  its  action  by 
the  time  the  pills  are  resumed.  By  proceeding  in 
this  manner,  you  will  always  avoid  the  possibility  of 
injuring  your  patient  with  mercury.  There  are  vari- 
ous other  forms  of  mercury  which  are  considered  elig- 
ible by  different  practitioners.  The  bicyanide  has 
been  known  to  agree  when  all  other  preparations  were 
not  tolerated.  The  red  iodide  has  been  especially 
recommended  in  the  late  scaly  eruptions.  A well- 
known  preparation  called  Zittman’s  decoction,  was 
formerly  much  used  in  Germany.  It  contains  mer- 
cury in  combination  with  sarsaparilla  and  aromatics. 

It  is  always  a matter  of  great  difficulty  to  induce 
our  patients  to  take  medicine  for  a sufficient  length 
of  time  to  effect  a cure.  They  are  prone  to  find  fault 
with  us  if  we  are  honest  with  them,  and  to  suspect  us 
of  sordid  motives  if  we  attempt  to  coerce  them  into 
prolonged  treatment.  It  is  a solemn  fact,  gentlemen, 
that  people  try  desperately  to  compel  the  physician 
to  be  dishonest.  They  mistake  honesty  for  lack  of 
skill,  and  will  more  readily  pay  the  quacks  huge  fees 
for  false  promises  and  blatant  pretenses,  than  the 
scientific  physician  a moderate  amount  for  skillful 
treatment.  They  have  always  at  their  tongue’s  end 
a long  list  of  their  friends  who  were  cured  of  a bad 
case  of  syphilis  (?)  by  Dr.  So-and-So,  in  three 
months.  In  spite  of  this  perverseness  of  human 
nature,  however,  it  is  our  duty  to  tell  your  patient 
that  if  he  wants  to  get  well,  he  must  take  medicine 
for  at  least  two  years,  and  if  any  doubt  exists  at  the 


2i8 


end  of  that  time  he  had  better  add  another  year, 
especially  if  he  has  matrimonial  intentions.  Allow 
no  syphilitic  patient  to  marry  under  three  years  from 
the  appearance  of  the  chancre,  if  you  would  have 
clear  consciences. 

Another  difficult  item  in  the  management  of  most 
cases  of  syphilis,  is  convincing  the  patient  that  it  is 
absolutely  necessary  for  him  to  avoid  the  use  of  liquor 
and  tobacco  for  an  extended  period,  and  that  he  must 
abstain  from  the  various  dissipations  and  excesses  to 
which  he  has  been  accustomed.  The  point  must  be 
insisted  upon,  however,  and  with  good  conduct  upon 
the  part  of  the  patient  assured,  half  the  battle  will 
have  been  gained.  The  late  Willard  Parker  used  to 
say  to  his  syphilitic  patients,  “You  are  possessed  of 
three  devils,  rum,  tobacco  and  syphilis.  If  you  will 
rid  yourself  of  the  two  former,  I will  rid  you  of  the 
latter.” 

In  some  cases  you  will  find  that  your  patient  does 
not  tolerate  mercury  well,  and  that  a diarrhoea  or 
gastric  disturbance  follows  the  slightest  attempt  to 
crowd  the  drug.  In  this  event,  one-eighth  grain  of 
ext.  hyoscyamus  should  be  added  to  each  pill.  A 
good  plan  too,  is  to  give  the  patient  a few  five  grain 
powders  of  bismuth  subnitrate,  with  instructions  to 
take  one  whenever  the  stomach  or  bow'els  become 
troublesome.  In  other  cases,  the  patient  will  stand  a 
large  amount  of  mercury,  and  I have  repeatedly  given 
several  grains  of  the  protiodide  daily  for  some  weeks, 
without  effecting  the  gums  or  the  digestive  tract  in 
the  slightest  degree.  In  such  cases  the  large  doses 
should  be  kept  up  for  a few  weeks,  and  then  dimin- 
ished to  about  four  or  five  pills  dail}’.  In  some  cases 
you  will  find  the  pil.  duo.  introduced  by  Dr.  Bum- 
stead  to  be  an  excellent  preparation,  especially  wdien 
the  patient  is  anaemic  and  debilitated.  The  pil.  duo. 
contains  gr.  ii.  of  pil.  hydrarg.  and  gr.  i of  ferri 
sulph.  exsiccat.  It  should  be  given  precisel}’  like  the 
protiodide.  It  usually  produces  constipation,  hence 
an  occasional  dose  of  hunyadi  or  bitcer  w'ater  may  be 
necessary. 


When  a patient  fails  to  respond  readily  to  the  in- 
ternal administration  of  mercury,  or  when  gastro- 
intestinal irritation  is  marked,  the  drug  may  be  used 
by  inunction.  The  oleate  is  the  best  preparation, 
although  too  expensive  for  some  patients.  The  twenty 
percent,  solution  should  be  used,  and  about  3i  rubbed 
into  the  axillae  morning  and  night.  As  the  axillae  be- 
come irratated,  the  rubbing  may  be  done  at  the  flex- 
ures of  the  joints,  where  the  skin  is  thin  and  absorp- 
tion readily  occurs.  The  mercurial  ointment,  though 
less  elegant,  may  be  used  as  a substitute  for  the  ole- 
ate. It  may  be  rubbed  in,  or  spread  upon  a white 
flannel  band  in  contact  with  the  abdomen,  the  band 
being  shifted  about  occasionally  and  the  skin  kept 
clean  by  daily  washing.  Another  good  plan  in  hos- 
pital practice,  is  to  rub  the  ointment  upon  the  soles 
of  the  feet,  and  have  the  patient  wear  heavy  woolen 
socks. 

In  some  cases  inunctions  or  baths  must  be  wholly 
depended  upon,  and  it  may  be  said  in  this  connec- 
tion, that  they  are  very  efficacious  in  obstinate  skin 
lesions.  Frictions  of  the  oleate  are  useful  in  rupia, 
and  will  also  assist  in  removing  the  induration  of  the 
primary  sore  unless  ulceration  exists,  in  which  case  it 
produces  irritation. 

A simple  method  of  giving  a mercurial  bath,  is  as 
follows : A small  tin  plate  supported  by  a tripod, 

an  alcohol  lamp,  and  a pan  of  boiling  water,  are  all 
that  is  necessary.  The  patient  being  stripped,  seats 
himself  in  a cane  bottomed  chair,  and  wraps  the 
chair  and  his  body  thoroughly  in  blankets.  About 
twenty  grains  of  the  mercurous  chloride  is  placed 
under  the  chair.  In  a few  minutes  the  calomel  is 
vaporized,  and  with  the  steam  from  the  boiling  water, 
is  deposited  upon  the  skin  of  the  patient.  In  fifteen 
minutes  the  lamp  may  be  extinguished,  and  after  ten 
minutes  more,  the  patient  should  wrap  himself  in  a 
dry  blanket  and  go  to  bed.  In  the  morning  he  may 
rub  himself  with  dry  towels,  the  mercury  having  be- 
come in  great  part  absorbed.  About  three  baths  per 
week  are  necessary.  Calomel  is  the  best  preparation 


220 


for  fumigation,  because  of  its  freedom  from  irritating 
properties,  and  the  readiness  with  which  it  volatilizes 
without  reduction  to  the  metallic  condition.  The  red 
oxide  also  volatilizes  readily,  but  its  fumes  are  more 
irritating  to  the  respiratory  tract. 

It  is  sometimes  necessary  to  bring  a patient  under 
the  influence  of  mercury  very  rapidly,^  e.  g. , in  cases 
of  syphilitic  iritis,  in  which  a few  hours  delay  might 
be  fatal  to  the  integrity  of  the  eyes.  In  such  an  event 
calomel  in  doses  of  iV  gr.  every  hour,  will  accomplish 
the  desired  result;  and  if  necessary,  ptyalism  can  be 
produced  in  this  manner  within  twenty-four  to  fort\’- 
eight  hours.  Another  method  of  rapid  and  efficacious 
introduction  of  mercury  is  by  Lewin’s  method  of 
hypodermic  injection.*  From  iV  to  ^ of  a grain  of 
the  bichloride,  in  combination  with  ^ gr.  of  morphia 
and  a small  quantity  of  sodium  chloride,  are  dissolved 
in  fifteen  minims  of  distilled  water,  and  injected  into 
the  cellular  tissue,  preferably  of  the  back,  once  or 
twice  daily,  f There  is  a vast  difference  in  the  suscep- 
tibility of  different  patients  to  these  injections.  I have 
never  seen  an  abscess  produced  by  them,  but  some 
patients  complain  bitterly  of  the  pain  following  their 
administration.  In  others,  hard  and  painful  indura- 
tions follow  their  use.  If  the  precaution  is  taken, 
however,  of  introducing  the  needle  well  into  the 
cellular  tissue  before  injecting  the  fluid,  very  little 
trouble  will  be  caused  in  the  majority  of  cases.  It  is 
probably  the  best  treatment  for  S3'philis,  in  a large 
number  of  cases,  if  you  can  get  j'our  patients  to  attend 
strictly  to  treatment.  As  an  adjunct  to  internal  treat- 
ment, the  injections  are  excellent,  and  I am  at  present 
giving  them  in  most  of  my  cases.  There  is  one  point 
to  which  I desire  to  call  attention,  viz. : the  bichloride 
makes  the  needle  very  brittle,  and  unless  )’ou  change 
it  frequently,  you  are  quite  likely  to  break  it  off  in  the 
tissues,  an  accident  which  the  patient  is  quite  liable 
to  criticise.  For  the  average  patient  in  the  hands  of 

-"Lewiii,  “BehandlTUbg  der  Syphilis,  mit  Subcutaner  Subliinat — injec- 
tion,” Berlin,  18(59. 

1 Stern,  Progres  Medicale,  Paris,  1878. 


■ 221 


the  general  practitioner,  it  is  probable  that  Lewin’s 
method  is  inferior  to  the  internal  use  of  the  mild 
iodide.  Abadie  urges  the  advantages  of  his  method 
of  subcutaneous  injections  of  mercuric  bichloride  in 
the  late  ocular  lesions  of  acquired  syphilis  and  con- 
stitutional syphilis.  “These  lesions  are  characterized 
by  their  complex  nature  and  the  slowness  of  their 
evolution.  Choro-retinitis  is  frequently  accompanied 
by  chronic  iritis,  and  even  by  parenchymatous  kera- 
titis. Many  of  these  cases  heal  spontaneously  with- 
out treatment,  while  others  show  a very  disquieting 
tenacity,  which  resists  all  treatment  until  the  hypo- 
dermic mercurial  injections  are  employed.  This  latter 
method  of  treatment  gives  good  results  also  in  certain 
forms  of  chorio-retinitis  limited  to  the  region  of  the 
macula.  In  cases  of  isolated  paralysis  of  the  cranial 
nerves  or  twigs  of  nerves,  without  cerebral  complica- 
tions, the  extreme  rebelliousness  of  the  trouble  is 
successfully  conquered  by  the  hypodermic  method  of 
treatment.”  For  this  purpose  Abadie  employs  a 
solution  of  mercuric  bichloride,  i part;  sodium  chlor- 
ide, 2 parts;  and  distilled  Avater,  io8  parts.  He  injects 
on  alternate  days,  20  drops  of  the  solution  beneath 
the  skin  of  the  back,  and  makes  gentle  massage  over 
the  spot  afterward.* 

An  interesting  method  is  the  treatment  of  syphilis 
by  intramuscular  injections  of  mercury.  Mr.  J.  Astley 
Bloxam  states  that  over  fifteen  hundred  patients  have 
been  treated  by  this  method  at  the  Lock  Hospital  and' 
elsewhere  during  the  past  eighteen  months,  with  the 
best  results.  “The  solution  for  injection  contains  6 
grains  of  the  bichloride  to  the  ounce  of  distilled  water, 
and  of  this  20  drops  constitute  a dose.  The  sore 
generally  begins  to  heal  very  promptly  after  one  or 
two  injections;  the  secondary  symptoms  are  markedly 
modified,  and  after  a course  of  treatment  extending 
over  a year,  more  or  less,  the  patient  is  enabled  to 
discontinue  his  attendance.  Toward  the  latter  end  of 
the  course  of  treatment  the  injections  may  be  given 


* Abadie,  Anuales  d’  Oculist,  May-June,  1886. 


222 


less  frequently,  and,  as  a rule,  not  more  than  from  8 
to  12  grains  of  the  perchloride  are  injected  in  all.  It 
is  undesirable  to  repeat  the  injections  oftener  than 
once  a week,  as  otherwise  salivation  might  be  induced, 
and  the  quantity  injected  each  time  of  a grain)  is 
found  to  be  quite  sufficient  until  the  next  time.  There 
are  several  advantages  attending  this  method  of  ex- 
hibiting mercury.  In  the  first  instance,  it  is  only 
necessary  to  see  the  patient  once  a week,  when  suffic- 
ient mercury  is  injected  to  last  until  the  following 
week;  secondly,  salivation  is  not  produced,  as  was 
apt  to  happen  when  the  patient  continued  to  take 
mercury  for  a whole  week  away  from  the  supervision 
of  his  medical  attendant;  thirdl)^  the  gastric  derange- 
ments which  are  so  apt  to  follow  the  administration 
of  mercury  by  the  mouth  are  by  this  means  avoided; 
lastly,  the  ease  and  certainty  of  the  administration 
which  enable  the  surgeon  to  do  his  own  dispensing 
with  a minimum  of  trouble.  A little  quinine  is  gen- 
erally given  during  the  course  as  a tonic,  but  no  other 
form  of  mercury  is  administered.  The  injections  are 
made  preferably  deep  into  the  muscular  mass  of  the 
glutei;  the  pain  following  is  slight  and  soon  passes 
away,  and  there  is  no  danger  of  an  abscess.* 

In  the  case  of  females  with  very  weak  stomachs,  or 
in  infantile  syphilis,  the  gray  powder  or  hydrarg.  cum 
creta  is  an  excellent  mercurial  preparation.  If  you 
have  to  crowd  the  mercurial,  do  so  by  superadding 
fumigations  or  inunctions,  rather  than  by  increasing 
the  internal  dose.  A preparation  recently  extolled 
abroad  is  the  tannate  of  mercury,  which  is  claimed  to 
be  perfectly  unirritating.  The  hydrargjTum  formida- 
tum  is  also  serviceable.  The  peptonate  is  another 
fanciful  preparation  used  by  our  French  confreres.  At 
the  next  lecture,  gentlemen,  we  will  give  our  attention 
to  the  evil  effects  of  mercury. 


*New  York  Medical  Journal,  October  23,  1886. 


LECTURES  ON  THE  TREATMENT  OF 
SYPHILIS. 


Lecture  II. 


Necessity  for  appreciating  the  evil  effects  of  mercury  when  improperly 
given.— Prejudice  against  its  use.— Depression  from  mercury. — Mer- 
curial ptyalism  and  stomatitis. — Care  of  the  teeth  during  a mercurial 
course,  to  prevent  ptyalism. — Causes  of  salivation.  — Treatment  of 
salivation  and  stomatitis. — Rheumatoid  pains  as  an  indication  of 
excessive  use  of  mercury.  —Pain  in  the  heels  and  soles  of  the  feet  from 
mercury.- Possibility  of  some  of  the  alleged  late  lesions  being  due  to 
mercury. — Action  of  iodine  preparations. — Iodides  in  precocious 
syphilis. — Methods  of  using  iodine  and  its  preparations. — Large  doses 
of  the  iodides  in  destructive  and  nervous  lesions. — Unpleasant  and 
injurious  effects  of  the  iodides  in  excessive  doses.— lodism  and  its 
treatment.— Iodine  eruptions. — Tendency  to  the  use  of  questionable 
preparations  in  syphilis. — Mistura  alteraus,  (McDade’s),  Tayuga, 
Potassium  bichromate,  Coca,  Iodoform  and  iron.— Local  management 
of  certain  syi^hilitic  lesions. — Necrosis  of  bones  in  late  S3^philis. 

Gentlemen  : — There  is  a strong  tendency  upon  the 
part  of  most  teachers  upon  the  subject  of  therapeutics 
to  speak  only  of  the  good  effects  which  are  claimed 
to  result  from  the  administration  of  various  drugs, 
and  to  avoid  the  discussion  of  those  evil  consequences 
which  are  likely  to  occur  at  the  hands  of  the  inex- 
perienced or  careless  practitioner — and  for  that  matter, 
at  the  hands  of  the  most  competent  men.  This  I 
believe  to  be  wrong,  and  I will  therefore  state  with 
reference  to  mercury,  that  it  is  a drug  which  must  be 
used  with  great  circumspection.  You  will  meet  with 
a very  firm  and  it  must  be  confessed,  fairly  well 
grounded  prejudice  against  its  use  existing  in  the 
minds  of  the  laity.  We  must,  of  course,  take  into 
consideration  the  fact  that  many  of  the  alleged  evil 
results  of  mercury  are  due  to  the  circumstance  that  its 
use  has  not  been  faithfully  persisted  in  for  a sufficient 
length  of  time,  but  with  all  this,  there  is  undoubtedly 
a certain  proportion  of  cases  in  which  serious  injury 
to  the  system  of  the  patient  may  be  justly  laid  at  the 

♦Delivered  at  the  Chicago  College  of  Physicians  and  Surgeons.  Re- 
ported by  William  Whitford. 


224 


door  attributed  to  this  remedy.  With  proper  care, 
however,  I venture  to  assert  that  there  is  no  drug 
which  is  safer  or  more  reliable,  and  I have  yet  to  see 
a single  case  of  permanent  injury  resulting  from  the 
drug,  when  properly  used. 

We  occasionally  meet  with  cases  in  which  mercury 
has  a very  unsalutary  effect  upon  the  patient,  in  the 
form  of  intense  mental  and  emotional  depression,  even 
when  very  moderate  doses  are  given.  In  such  cases 
it  may  be  necessary  to  give  tonics  and  even  stimulants, 
in  order  to  counteract  this  condition.  Or  it  nia}^  even 
be  necessary  to  stop  the  mercury  entirely,  and  depend 
upon  potassium  iodide.  Coca  will  be  found  useful  in 
such  cases. 

One  of  the  most  frequent  of  the  injurious  effects 
produced  by  mercury  is  ptyalism.  Salivation  in  any 
marked  degree  is  alwa3's  injurious,  and  no  more  pro- 
nounced effect  should  ever  be  produced  than  a slight 
redness  and  tenderness  of  the  gums,  with  a slight  in- 
crease in  the  salivarj'  secretion,  a copper}^  taste  in  the 
mouth,  and, — what  is  often  a good  indication  to 
diminish  the  amount  of  mercury, — a sensation  as  if 
the  teeth  were  too  long.  To  this  latter  s3'mptom  I 
desire  to  call  especial  attention.  Ulceration  of  the 
cheeks  or  gums  sometimes  occurs  without  previous 
salivation,  but  this  is  quite  rare.  To  prevent  these 
anno3mnces,  the  mouth  and  teeth  ought  to  be  put  in 
thorough  order  by  the  dentist  prior  to  beginning  treat- 
ment. Tartar  should  be  removed  and  the  teeth 
cleaned,  and  all  those  which  are  decayed  either  ex- 
tracted or  filled. 

The  causes  of  salivation  are  iodios3mcras3'  or  renal 
inactivity  with  moderate  doses  of  mercur3%  or  large 
doses  without  iodios3mcras3'.  Diseases  of  the  mouth 
and  gums  predispose  to  it,  and  sometimes  exposure 
to  cold  and  wet  during  a mercurial  course  will  bring  it 
on.  The  elimination  of  mercur3r  from  the  S3'Stem, 
being  chiefly  through  the  medium  of  the  kidne3's,  we 
may  best  guard  against  ptyalism  and  other  cumulative 
evil  effects  of  the  drug  by  the  administration  of  diur- 


— 225  — 


etics  and  the  use  of  hot  baths.  Ptyahsm  will  not  be 
apt  to  occur  as  long  as  the  kidneys  are  not  inhibited 
in  the  performance  of  their  eliminative  function. 
Iodide  of  potassium  assists  in  the  elimination  of  mer- 
cury, chiefly  through  its  stimulating  action  upon  renal 
secrection.  Exposure  to  cold  and  wet  during  a mer- 
curial course  causes  ptyahsm,  through  the  reflex 
hyperaemia  and  consequent  inhibition  of  function  of 
the  kidneys  incident  to  a severe  cold.  Under  such 
circumstances,  jaborandi  is  our  most  rational  remedy. 
When  salivation  occurs,  it  requires  treatment.  Oi 
course  the  first  thing  to  do  is  to  stop  the  mercurial. 
The  chlorate  of  potassium  may  be  given  internally, 
and  a mouth  wash  used  composed  of  the  chloride  of 
potassium  and  tincture  of  myrrh,  in  the  proportion  of 
5 i.  of  the  potass,  chloride  and  5 i.  of  tr.  of  myrrh 
to  5 iv.  of  water.  Glycerine  may  be  added  if  desired. 
Remember  to  specify  the  chloride  of  potassium  and 
not  the  chlorate,  in  this  mixture.  In  some  severe 
cases  of  salivation  the  patient  cannot  swallow  solid 
food,  and  whether  this  be  the  case  or  not  fluid  aliment 
is  indicated.  As  already  indicated,  the  skin  and  kid- 
neys require  attention.  Relieve  the  strain  upon  the 
kidneys  by  the  Turkish  bath  and  jaborandi,  and  at 
the  same  time  flush  out  the  kidne3's  by  copious 
draughts  of  hot  water  in  combination  with  the  citrate 
of  potassium.  It  is  not  wise  to  give  the  iodide  of 
potassium  at  first,  as  it  may  enhance  the  difficulty  by 
liberating  still  more  mercury  which  has  become  stored 
up  in  the  system.  As  the  case  improves,  it  may  be 
given  with  great  benefit.  I hope  that  you  may  see 
a case  of  mercurial  salivation  sometime  in  the  practice 
of  someone  else,  as  a sort  of  warning  to  you  regard- 
ing the  abuse  of  a really  excellent  drug.  The  fetor 
of  the  breath  in  these  cases  is  something  horrible,  and 
is  due  to  the  presence  of  decomposing  fat  in  the  saliva, 
produced  by  the  action  of  mercury  upon  the  tissues, 
and  eliminated  by  the  salivary  glands.  In  some  cases 
of  mercurial  stomatitis,  the  cheeks,  tongue  and  lips 
are  fearfully  swollen,  perhaps  ulcerated,  and  covered 


226 


with  a yellowish  pultaceous  deposit,  which  is  emi- 
nently characteristic. 

You  will  find  in  certain  instances  chronic  pains  of  a 
rheumatic  character,  muscular  and  articular,  resulting 
from  mercury,  and  I have  learned  by  experience  that 
when  a patient  who  is  taking  much  mercury  begins  to 
complain  of  vague  pains  in  the  forearms  and  legs,  it 
is  time  to  drop  mercury  and  give  iodine.  There  is 
one  peculiar  fact  which  is  worthy  of  mention,  and 
that  is  that  some  patients  complain  bitterly  of  pain 
in  the  heels  and  sometimes  the  soles  of  the  feet,  simi- 
lar to  that  which  occurs  in  gonorrhoeal  rheumatism. 
This  is  probably  due  to  mercury.  When  your  patient 
complains  of  his  feet  being  tender,  lessen  the  amount 
of  mercury  and  give  the  iodides,  if  you  would  save 
yourself  trouble.  There  is  a serious  question  in  my 
mind  whether  some  of  the  ulcerations  of  the  mouth 
and  tongue  in  the  later  periods  of  syphilis  may  not  be 
due  to  mercury.  I see  many  such  cases  in  which  the 
continued  use  of  the  drug  appears  to  make  matters 
worse,  and  I find  that  when  iodides  are  substituted 
improvement  at  once  occurs.  This  might  be  attrib- 
uted to  the  action  of  the  iodine  in  liberating  and 
revivifying,  so  to  speak,  the  latent  mercur}^  but  I 
doubt  it  being  the  correct  explanation.  We  occasion- 
ally meet  with  cases  of'  syphilis  in  practice  that  will 
put  us  at  our  wit’s  end  for  suitable  remedies.  One  of 
my  patients  is  a case  in  point.  The  case  is  that  of  a 
lady  aged  twenty-six,  who  has  been  suffering  from  an 
attack  of  syphilis  for  the  last  year.  She  has  gone 
through  successive  eruptions,  with  their  concomitant 
lesions,  while  under  active  treatment.  Thus  she  has 
had  the  roseola,  followed  by  a papulo- squamous 
syphilide  with  mucous  patches  of  a severe  t}'pe,  a 
tuberculo-squamous  eruption  followed  by  ulcerations, 
and  accompanied  by  condylomata  and  two  attacks  of 
iritis.  Now  I am  positive  that  this  patient  is  made 
worse  by  mercury,  but  her  stomach  is  so  irritable  that 
iodides  are  not  tolerated  for  any  length  of  time,  and  I 
am  forced  to  rely  for  the  most  part  upon  tonics,  coca 
having  acted  best  of  any  which  have  been  tried. 


227 


The  use  of  the  iodides  in  syphilis  requires  some 
special  notice.  The  active  element  in  the  iodides  is 
supposed  to  be  the  free  iodine  which  is  liberated  in 
the  system,  but  there  seems  to  be  some  difference  in 
the  degree  of  effect  exerted  by  the  various  salts.  The 
potassic  iodide  is  the  most  powerful,  but  is  most  liable 
to  produce  gastro-intestinal  irritation.  This  does  not, 
however,  impair  its  usefulness  to  any  great  extent,  for 
it  is  the  most  generally  used  of  all  the  preparations  of 
iodine.  The  sodic  salt  is  milder,  and  is  a useful  sub- 
stitute for  the  potassic  iodide,  where  the  patient  has  a 
feeble  or  irritable  digestive  apparatus.  The  iodides 
are  often  and  successfully  used  in  combination,  the 
ammonium  iodide  being  combined  with  the  iodides  of 
potassium  and  sodium.  Pure  iodine  is  useful,  but 
usually  too  irritating. 

It  is  the  custom  with  most  practitioners  to  use 
iodine  and  its  preparations  only  in  the  late  periods  of 
the  disease,  and  chiefly  in  tertiary  lesions,  but  it  will 
be  found  that  many  cases  of  .obstinate  secondary 
lesions  will  not  yield  until  the  iodides  are  given.  As 
I have  already  stated,  it  is  well  to  give  a few  weeks’ 
course  of  the  iodides  from  time  to  time  throughout 
the  course  of  mercurial  treatment.  A small  amount 
of  the  biniodide  may  be  given  at  the  same  time  if 
thought  best.  In  cases  of  precocious  syphilis,  in 
which  destructive  lesions  or  nervous  changes  come  on 
early  in  the  disease,  the  iodides  are  our  chief  reliance. 
It  is  in  late  syphilis,  however,  that  the  iodides  will  be 
found  most  reliable,  especially  if  combined  with  mer 
cury  in  the  form  of  “mixed  treatment.”  Gummy 
lesions  require  an  excess  of  the  iodides,  but  in  all 
cases,  after  the  serious  lesions  are  under  control,  a 
prolonged  mild  mercurial  course  should  be  instituted. 
This  is  the  proper  method  of  treating  the  deeper 
lesions  of  the  brain,  spinal  cord,  bones,  viscera,  testi- 
cle, etc.,  the  tubercular  lesions  of  various  kinds,  the 
various  scaly  eruptions,  and  those  later  syphilides 
which  tend  to  aggregate  themselves  in  groups,  or  to 
become  particularly  obstinate.  As  an  example  of  the 


228 


formulae  for  the  mixed  treatment,  I will  give  you  a 
quite  popular  combination ; 


3^  Hydrarg.  bichlor gr-  iv 

Ammon,  iod 5 iii 

Kalii  iod 5 vii 


Tr.  Cinchon.  Co.  orSjT.  Sarsap.  Co..  § iv 
M.  Sig. — 5ii-  ill  wineglassful  of  water  after  each 
meal. 

Where  it  is  desirable  to  use  an  alterative  tonic  in 
combination,  I frequently  give  the  elixir  of  the  three 
chlorides.  This  is  a very  reliable  and  elegant  mixture 
prepared  by  Renz  & Henry,  of  Louisville.  It  is  not 
a quack  or  secret  remed}q  nor  is  it  recommended  as  a 
cure-all,  and  I have  no  hesitancy  in  endorsing  it.  I 
might  remark,  by  the  way,  that  I seldom  endorse 
special  preparations,  but  I do  feel  at  liberty  to  en- 
dorse some  of  our  modern  therapeutical  elegancies, 
the  formulae  of  which  are  known.  The  formula  for 
the  elixir  of  the  three  chlorides  is  as  follows  : 


3^  Proto-chloride  of  iron gr. 

Bichloride  of  mercury gr. 

Chloride  of  arsenic gr.  -oL 

Calisaya  alkaloids  and  aromatics  q.  s. 

M. 

A desirable  formula  is  as  follows  : 

3^  Kalii  iod 5 '’'i 

Ammon,  chloridi 5 ''i' 

Elix.  Chlorides  Co.  (R.  and  H.).  . . § iv 
M.  Sig. — 5 i to  5 ii  after  each  meal. 

When  it  is  necessar}'  to  stop  active  treatment  I 


frequently  give  a tonic  course  of  the  elixir  of  the 
chlorides  alone. 

The  late  Prof.  Gunn’s  “three-eights”  mixture  is 
an  excellent  one  for  the  administration  of  iodine. 


It  is  as  follows  : 

3^  lodinii  Resubl gr.  viii 

Potass,  iodidi 5 '’iii 

Syr.  Sarsap,  Co 5 viii 

M.  Sig. — 5 i dose. 


22g  — 


Always  instruct  your  patients  to  dilute  these  prepa- 
rations well  before  taking,  as  they  are  all  more  or  less 
irritating  to  the  stomach,  and,  as  far  as  possible,  to 
take  them  after  meals.  In  some  instances,  however, 
in  which  the  patient’s  digestive  organs  are  not  very 
sensitive,  the  iodides  may  be  taken  with  advantage 
while  fasting,  especially  if  combined  with  a vegetable 
bitter,  like  quassia  or  cinchona.  In  the  formulae 
which  I have  given  you  for  the  mixed  treatment,  you 
are  likely  to  criticise  the  combination  of  incompatibles 
and  the  administration  of  the  irritating  bichloride,  but 
if  you  reflect  you  will  see  that  the  ingredients  are 
rationally  compatible,  although  not  chemically  so. 
We  have  a chemical  reaction  in  the  mixture,  which 
results  in  the  formation  of  the  biniodide,  which  is  very 
active  by  virtue  of  its  being  in  the  nascent  condition. 
When  it  is  necessary  to  push  the  dose  of  the  iodides, 
do  so  by  adding  a saturated  solution  of  sodic  or 
potassic  iodide,  to  be  taken  in  doses  of  five  drops 
thrice  daily  to  begin  with,  and  to  be  subsequently  in- 
creased one  drop  daily  at  each  dose,  until  the  limit  of 
tolerance  has  been  reached,  or  until  the  symptoms 
yield,  when  the  dose  may  be  reduced,  the  favorable 
result  meanw’hile  continuing.  It  is  sometimes  neces- 
sary to  use  mercurial  inunctions  in  addition  to  the 
iodides,  and  the  local  application  of  the  oleate  some- 
times assists  in  the  cure  of  the  lesions  amazingly. 

The  deep-seated  ulcerations, — especically  those  of 
the  throat, — syphilis  of  the  bones,  and  syphilis  of  the 
brain  and  cord,  often  require  enormous  doses  of  the 
iodides  before  they  exhibit  any  signs  of  yielding.  In 
the  venereal  wards  of  the  New  York  Charity  Hospital, 
a daily  dose  of  two  or  three  hundred  grains  of  potas- 
sic iodid  was  nothing  unusual,  and  Van  Buren  relates 
a case  in  which  nine  hundred  grains  were  given  daily 
for  eleven  days.  In  my  own  service  we  had  several 
cases  in  which  the  drug  was  increased  to  a daily  al- 
lowance of  four  hundred  grains.  I must  acknowledge, 
however,  that  I was  never  fully  satisfied  as  to  the  pur- 
ity of  our  hospital  drug,  and  Van  Buren  himself  told 


230  — 


me  that  he  did  not  believe  it  possible  for  a patient  to 
tolerate  the  amount  of  iodide  which  we  so  commonly 
gave  at  the  hospital,  if  the  drug  were  pure.  It  would 
seem  that  a patient’s  kidney’s  would  be  rather  worth- 
less, after  eleven  days  work  at  the  daily  elimination 
of  two  ounces  of  the  iodide.  Making  due  allowance 
for  adulteration  however,  the  doses  which  some 
patients  will  tolerate  are  amazing.  I have  several 
patients  who  have  taken  three  hundred  grains  dail}' 
for  two  to  three  weeks,  and  I am  certain  that  the  drug 
was  perfectly  pure.  On  the  other  hand  we  meet  with 
cases  which  will  not  tolerate  even  small  doses  of  the 
iodides.  The  tolerance  of  potassium  iodide  exhib- 
ited by  different  patients,  greatly  depends  upon  the 
general  common  sense  management  of  the  consti- 
tutional condition.  The  iodides  will  produce  great 
debility  and  wasting  when  given  in  large  doses,  unless 
great  care  be  used.  Nearly  all  cases  of  late  syphilis 
are  suffering  with  two  things,  viz  : the  debility  pro- 
duced by  long  continued  S5'philis,  and  the  pallor  and 
anaemia  incident  to  injudicious  mercurial  treatment. 
Great  care  is  always  necessary  in  such  cases  to  keep 
up  general  nutrition.  If  the  syphilis  per  se,  be 
repeated,  injury  is  apt  to  be  done,  but  if  the  syphilis 
be  relegated  to  the  back  ground,  and  the  patient  him- 
self attended  to,  much  good  ma}"  be  accomplished. 
Many  patients  who  have  sequelae  of  s}’philis  and  who 
have  taken  more  or  less  mercury  in  time  past,  will 
tell  you  that  they  “cannot  stand  mercury.”  To  such 
patients  you  may  safely  say  that  the}"  not  only  can 
stand  mercury,  but  that  they  can  take  it  and  growfat 
at  the  same  time.  Mercury  produces  effects  which 
vary  greatly  according  to  the  idiosyncrasy  and  resist- 
ing power  of  the  patient,  and  the  dose,  preparations 
and  method  of  administration  of  the  drug.  Given  in 
minute  doses  in  combination  with  the  iodide,  it  acts 
as  a powerful  tonic.  The  proper  method  of  admini- 
stration of  the  iodides,  is  in  the  form  of  the  saturated 
solution,  as  above  designated.  At  the  same  time,  the 
formula  for  the  mixed  treatment  with  a dose  of  the 
bichloride  not  to  exceed  1-32  of  a grain  should  be 


— 231- 


given.  Cod  liver  oil  and  iron  are  always  necessary  in 
these  cases.  The  oil  may  be  given  as  an  emulsion, 
and  the  iron  in  the  form  of  the  diolysed  of  syrup  of 
the  iodide.  An  illustrative  of  the  excellent  effects  of 
this  method  or  management  the  following  cases  from 
my  note  book  may  be  of  interest,  although  in  no 
sense  remarkable. 

Case  i.  A physician  of  thirty-five  contracted  syph- 
ilis at  the  age  of  twenty-eight,  and  went  through  a 
more  than  ordinarily  severe  course  of  the  disease. 
Two  years  after  the  commencement  of  his  trouble, 
extensive  ulcerations  appeared  upon  his  right  leg, 
and  as  the  veins  of  this  limb  were  varicose,  the  lesions 
proved  very  obstinate,  and  up  to  the  time  of  his  con- 
sulting me  had  never  been  perfectly  healed.  In  the 
mean  time  the  patient  had  become  thoroughly  dis- 
gusted with  mercury  on  account  of  injudicious  treat- 
ment early  in  his  case.  At  the  time  I first  saw  him, 
debility  was  quite  marked.  Potassium  iodide  in  in- 
creasing doses,  and  1-32  of  a grain  of  the  bichloride 
were  ordered,  and  later  on,  a mixture  of  syr.  ferri 
iod.  and  ol.  morrhuae.  Antiseptic  strapping  consti- 
tuted the  local  treatment.  The  oil  and  iron  were 
ordered  in  sherry  wine  after  meals,  and  the  patient 
was  as  much  surprised  as  he  was  gratified  at  this 
prescription, — which  by  the  way  is  always  useful  in 
these  chronic  cases.  Improvement  was  quite  rapid, 
and  the  patient  gained  fourteen  pounds  in  about  four 
weeks,  the  ulcer  meanwhile  cicatrizing  completely. 

Case  2.  A lady  of  thirty  consulted  me  in  regard  to 
necrosis  of  the  palate,  nasal  and  superior  maxillary 
bones.  I removed  small  portions  of  necrosee  bone 
from  time  to  time,  and  advised  tonic  doses  of  mercury 
with  increasing  doses  of  the  iodide,  in  combination 
with  oil  and  iron.  Although  she  was  much  debil- 
itated, I increased  the  dose  of  iodide  until  the  patient 
was  taking  one  hundred  and  eighty  grains  per  diem, 
and  with  the  best  results.  The  nose  and  throat  im- 
proved, the  necrosis  ceased,  and  the  patient  gained 
about  twelve  pounds  in  the  course  of  a month. 


-232- 


Case  3.  This  case  vv'as  that  of  a gentleman  of 
thirty-three,  who  had  lesions  of  the  nose  and  pharynx 
similar  to  those  of  case  2.  Anaemia  was  not  marked, 
but  wasting  was  quite  pronounced.  The  patient 
stated  that  he  could  not  take  potassium  as  it  dis- 
turbed his  stomach  and  made  him  grow  thin.  Under 
the  usual  routine  treatment  which  I have  recom- 
mended, this  patient  was  finally  given  nearly  two 
hundred  grains  of  potassic  iodide  daily,  for  at  least 
two  weeks.  At  the  end  of  three  weeks  treatment 
he  had  gained  seventeen  pounds  in  weight,  and  was 
correspondingly  happy.  At  the  end  of  six  weeks  this 
patient  went  home  in  better  health  than  at  any  time 
since  he  contracted  his  syphilis. 

I might  describe  a number  of  similar  cases  from  1115^ 
private  practice,  but  I think  that  the  three  histories 
which  have  been  given  you  are  a fair  illustration  of 
what  judicious  treatment  can  do,  and  consequent!}^  of 
much  value  as  a dozen  would  be  to  you. 

Like  the  unpleasant  effect  of  mercury,  those  of 
iodine  require  more  than  casual  attention.  In  the 
first  place,  the  iodides  may  cause  sudden  and  severe 
ptyalism  in  patients  who  have  been  taking  mercury 
freely,  simply  by  suddenly  liberating  and  rendering 
active  the  latter  drug.  On  this  account,  caution 
should  be  exercised  in  the  use  of  the  iodides  in  such 
cases  as  have  been  under  a prolonged  course  of  mer- 
curials. You  will  find  in  every  case,  that  the  iodine 
has  a special  action  upon  the  salivary  glands,  whether 
the  patient  has  been  taking  mercury  or  not.  If  you 
will  take  a ten  grain  dose  of  the  iodide  of  potassium, 
you  will  find  that  you  can  taste  the  iodine  most  dis- 
tinctly in  a very  short  time,  and  that  your  saliva,  and 
the  mucus  from  your  nasal  passages,  will  e.xhibit  a 
decidedly  yellowish  tinge.  The  nasal  mucus  especi- 
ally, will  be  greatly  increased  in  amount. 

The  most  important  of  the  evils  which  may  be 
caused  by  the  iodides  is  the  condition  known  as 
“iodism.”  This  consists  in  a feeling  of  depression 
and  malaise,  nervous  irritability,  tinnitus  aurium, 


— 233  — 


neuralgic  or  rheumatic  pains  in  various  situations, 
especially  in  the  bones  and  muscles,  and  irritation  of 
the  various  mucous  surfaces,  especially  those  of  the 
eyes  and  nose.  The  latter  symptom  may  be  merely 
a mild  coryza  or  may  amount  to  a very  severe  inflam- 
matory oedema  of  the  conjunctiva,  nasal  and  lachrymal 
apparatuses.  Severe  diarrhoea  and  vomiting,  with 
severe  griping  pain,  may  occur  from  the  irritant  action 
of  the  drug,  and  may  necessitate  its  complete  suspen- 
sion for  a time.  Often,  however,  the  treatment  may 
be  continued  by  substituting  the  sodium  for  the  potas- 
sium salt,  limiting  the  diet  to  rice  and  milk,  and  giv- 
ing large  doses  of  the  subnitrate  of  bismuth.  When 
given  as  I have  already  suggested,  by  beginning  with 
small  doses  and  gradually  increasing  until  the  limit  of 
tolerance  is  reached,  there  is  usually  little  dhiiculty  in 
administering  large  doses  of  the  iodides. 

Eruptions  of  the  skin  are  liable  to  occur  from  the 
iodides,  and  some  patients  appear  to  have  an  idiosyn- 
crasy which  renders  them  peculiarly  liable  to  the 
occurrence  of  eruptive  phenomena,  even  when  quite 
small  doses  are  given.  I have  a patient  at  the  pres- 
ent time  who  cannot  take  the  iodide  in  ten  grain  doses 
for  a day  without  the  development  of  red  painful 
swellings  upon  his  limbs.  In  the  same  way  we  find 
patients  who  are  liable  to  extreme  iodism  from  very 
small  doses.  A professional  gentleman  of  my  ac- 
quaintance cannot  tolerate  the  drug  in  doses  of  two  or 
three  grains  without  the  development  of  a severe 
coryza  in  a few  hours.  Another  of  my  patients  de- 
velops iodism  within  a few  minutes  after  spraying  the 
throat  with  a weak  iodine  solution. 

There  are  three  principal  forms  of  eruption  which 
may  result  from  iodine  and  the  iodides,  viz. : acne, 
erythema,  and  purpura.  Of  these  eruptions  acne  is 
the  most  frequent,  and  may  be  slight  or  quite  exten- 
sive, the  pustnles  varying  from  the  size  of  the  head  of 
a pin  to  quite  extensive  phlegmonoid  abscesses. 
Erythema,  when  it  occurs,  is  usually  situated  upon 
the  nose,  cheeks  or  forehead,  and  is  followed  by 


234  — 


branny  desquamation.  It  may,  however,  run  into 
eczema.  Any  of  these  forms  of  eruption  may  be 
attended  by  considerable  heat  and  itching. 

Severe  and  well  marked  purpura  hemorrhagica  is 
occasionally  noted  in  cases  of  tertiary  syphilis  treated 
by  large  doses  of  the  iodide  of  potassium.  In  such 
cases  we  have  the  combined  evil  propensities  of  the 
syphilitic  cachexia  and  large  doses  of  iodine  to  explain 
the  profound  blood  changes  to  which  the  purpuric 
extravasations  are  attributable.*  Fatal  cases  of 
iodine  poisoning  have  been  reported,  hence  a certain 
amount  of  caution  must  be  exercised  in  cases  in  which 
there  is  a marked  contra-indicating  idiosyncrasy.  Dr. 
Wolf,  of  Goritz,  has  reported  a case  recently  of  a man 
with  cardiac  hypertrophy  and  “subacute  kidney 
disease,”  who  died  as  a result  of  the  administration  of 
thirty  grains  of  potassic  iodide  in  about  thirty-six 
hours.  It  is  quite  easy  to  explain  this  case  indepen- 
dently of  any  idiosyncrasy.  The  irritating  effect  of 
the  iodide  completely  suspended  the  action  of  the 
kidneys,  which  were  already  impaired  by  disease. 
Such  cases  are  useful  in  impressing  hpon  us  the 
necessity  of  care  in  our  treatment  of  patients  with 
renal  disease. 

All  of  the  evil  effects  of  the  iodides  rapidl}'  disap- 
pear upon  the  cessation  of  the  drug,  and  the  adminis- 
tration of  such  tonics  as  quinine,  iron,  and  cod  liver 
oil,  with  free  doses  of  such  diuretics  as  the  citrate  or 
acetrate  of  potassium.  The  cause  of  the  evil  phe- 
nomena described  is  usually  defective  action  of  the 
kidneys,  hence  the  advisability  of  promoting  free 
diuresis  during  a course  of  the  iodides.  Acne,  in 
certain  special  cases  of  idiosyncrasy,  may  be  pre- 
vented by  the  administration  of  Fowler’s  solution 
of  arsenic,  conjointl}^  with  the  iodides.  A recent 
paper  on  “lodinism”  by  Dr.  E.  J.  Kemph,  published 
in  the  Medical  Herald,  gives  some  excellent  deduc- 


* Otis  claims  to  have  seen  patches  resembling’  diphtheritic  deposit 
npon  the  mucous  membranes  as  a result  of  the  iodides. 


— 235  — 


tions  regarding  the  administration  which  will  bear 
repetition.  The  author  gives  the  following  resume  of 
his  paper : 

“I.  Large  draughts  of  water  taken  immediately 
after  the  drug  prevents  the  more  severe  effects  of 
iodinism  by  diluting  the  salt  and  causing  its  rapid 
elimination.  If  starch  water  is  not  immediately  on 
hand,  pure  water  should  be  largely  given  to  one  pois- 
oned with  iodine. 

“2.  The  tolerance  of  iodine  varies  greatly  in  differ- 
ent subjects.  A dram  of  tincture  of  iodine  caused 
one  individual  no  inconvenience,  and  five  drops  of  the 
same  tincture  caused  active  symptoms  of  iodinism  in 
another. 

“3.  This  variation  makes  iodine  an  unreliable 
remedy,  and  it  should  induce  us  to  commence  with 
the  smallest  dose  allowable  in  any  case.  If  the 
patient  bears  it  well  we  can  increase  the  dose,  and 
besides  it  is  a well-known  fact  that  the  individual  will 
become  habituated  to  the  drug,  and  the  danger  of 
inducing  iodinism  will  be  reduced  to  a minimum. 

“4.  The  tincture  of  iodine  is  the  preparation  of 
the  drug  most  likely  to  cause  iodine  poisoning  by  mis- 
take, as  only  one  drop  more  than  is  prescribed  may  be 
sufficient  to  cause  iodinism.  The  tincture  ought  never 
to  be  used  internally,  as  there  are  other  and  more 
reliable  preparations  of  iodine  that  may  be  used  when 
the  remedy  is  indicated. 

“ 5.  Children  especially  should  be  watched  when 
taking  iodine  preparations,  though,  as  a rule,  they 
bear  the  drug  in  proper  doses  as  well  as  adults.” 

There  is  a great  tendency  on  the  part  of  the 
profession  to  recommend  various  new  and  question- 
able preparations  in  the  treatment  of  syphilis.  Cer- 
tain vegetable  preparations  have  enjoyed  a more  or 
less  long-lived  popularity  in  this  respect.  Sarsapa- 
rilla was  long  thought  to  be  a specific.  Among  the 
new  preparations  are  cascara  amarga,  berberis  aqua- 
folium,  stillingia  and  other  drugs,  alone  or  in 
combination.  I advise  you  to  try  these  things,  in  the 


— 236  — 


firm  belief  that  you  ■will  soon  discov^er  their  fallacies 
and  come  back  to  our  reliable  friends,  iodine  and 
mercury.  As  bitter  tonics  they  are  all  more  or  less 
useful,  but  as  specifics  they  are  arrant  humbugs.  A 
certain  quasi-patent  medicine,  known  as  “ McDade’s 
Mixture,”  and  composed  of  various  vegetable  ingre- 
dients, was  introduced  some  time  ago,  and  I am  sorr)’ 
to  say  was  fathered  by  no  less  a man  than  the  late 
Marion  Sims,  and  indorsed  by  some  other  very  good 
men,  who  must  feel  proud  of  the  distinction  of  having 
attached  their  testimonials  to  a remedy  rvliich  has 
since  been  heralded  in  every  newspaper  as  the  popular 
remedy  for  syphilis.  As  a matter  of  fact,  it  is  on  a 
par  with  its  quite  as  respectable  contemporar}',  the 
three  S’s,  as  a therapeutic  agent.  Ta)'uga,  another 
remedy  of  doubtful  origin  which  was  recommended 
some  years  ago,  has  been  given  a fair  trial  in  S3’philis, 
but  with  negative  results.  The  bichromate  of  potas- 
sium has  been  recently  recommended,  but  I have  had 
no  experience  with  it.  This  drug  was  first  introduced 
by  J.  Edmund  Giiiitz,  of  Dresden,  who  claims  sur- 
prisingly good  results  from  its  use.  He  at  first  gave 
gr.  iV  in  combination  with  potassium  nitrate  three 
times  a da}',  but  subsequent!)'  found  a better  effect 
from  what  he  styles  “ chromwasser,”  which  consists 
of  a solution  of  potassium  bichromate  in  carbonic 
acid  water.  With  this  preparation  he  claims  to  be 
able  to  give  3^  grains  of  the  drug  daily,  the  quantity 
of  carbonated  water  necessary  being  about  6,000 
grammes.  The  remedy  is  to  be  given  after  meals. 
Giintz  claims  that  this  remed)'  is  curative  in  syphilis 
on  account  of  its  powerful  oxidizing  properties. 

It  is  best  to  be  liberal,  and  give  different  remedies 
a fair  trial,  irrespective  of  their  origin,  and  such  has 
been  my  custom,  but  I think  that  )'ou  will  find  that 
the  proportion  of  cases  of  syphilis  which  is  curable 
by  the  judicious  use  of  mercury  and  iodine  is  so  large 
and  so  gratifying  that  you  Avill  waste  no  unnecessari- 
time  upon  new  and  strange  drugs.  *1.  In  conclu- 
sion I \vill  mention  two  remedies  which  are  decidedly 


— 237  — 


beneficial  as  tonics  in  syphilis,  viz. : the  fi.  extract  of 
coca  and  iodoform.  Coca  is  an  excellent  tonic  when 
used  conjointly  with  strictly  anti-syphilitic  treatment, 
and  tends  decidedly  to  relieve  the  nervous  depression 
from  which  most  syphilitics  suffer.  f2.  Iodoform 
will  be  found  most  useful  in  cases  which  do  not  tolerate 
mercury  and  iodine  well,  and  should  be  combined  with 
the  exsiccated  sulphate  of  iron  or  the  iron  by  hydro- 
gen, the  latter  perhaps  being  the  most  useful  and  con- 
venient. There  are  two  other  drugs  which,  while  not 
in  any  sense  curative,  will  be  found  beneficial  in 
syphilis.  These  are  the  potassium  chlorate  and  am- 
monium chloride.  The  former  in  doses  of  a table- 
spoonful of  the  saturated  solution  thrice  daily  seems 
to  act  very  nicely  when  conjoined  with  the  regular 
mercurial  course,  particularly  when  oral  or  facial 
lesions  are  prominent  symptoms.  The  ammonium 
chloride  assists  in  dissolving  the  young  connective 
tissue  or  plastic  deposit  which  forms  the  bulk  of  syph- 
ilitic lesions.  It  has  seemed  especially  useful  in 
nervous  syphilis.  It  is  best  given  in  combination  with 
the  ordinary  mixed  treatment.  Dr.  Dumesnil,  of  St. 
Louis,  also  claims  excellent  results  from  this  drug. 

In  the  syphilitic  cachexia,  and  particularly  in  that 
attendant  upon  the  last  stages  of  the  disease,  the 
chloride  of  gold  and  sodium  is  very  valuable.  I have 
used  it  hypodermically  quite  extensively,  and  am  con- 
vinced of  its  efficacy.  In  bone  and  nervous  lesions  it 
is  of  especial  value.  Combined  with  the  elixir  of  the 
three  chlorides,  of  which  I have  already  spoken,  it 
can  with  great  advantage  be  given  internally.  The 
following  is  a serviceable  formula: 


‘-J^Bumstead  and  Taylor  estimate  the  proportion  of  ciu’es  at  about  95 
per  cent,  but  this  is  somewhat  exag’gerated.  +2.  Dr,  Taylor,  Of  New 
York,  also  praises  the  erythroxylon  coca  as  follows:  ‘‘Its  marked  tonic 

eifect  upon  the  heart,  nervous  system,  and  capillaries,  and  its  power  to 
invigorate  the  system,  to  improve  nutrition,  and  to  sustain  life,  is  so 
great  that  its  use  in  syphilis,  secondarv  to  that  of  mercury  and  iodide 
of  potassium,  is  attended  by  results  which  no  other  agent  known  to  us 
possesses.  It  is  especially  useful  in  the  anaemia  and  cachexia  of  the 
secondary  period.’'  He  further  especially  emphasizes  its  great  value 
in  “marked  debilitated  and  cachectic  conditions.'’ 


— 238 


Aurii  et  sodii  chlor gr.  ii 

Elix.  chlorides  Co 5 iv 

(R.  and  H.) 


M.  Sig.  5i- — After  each  meal. 

Before  leaving  the  subject  of  the  treatment  of 
syphilis,  I desire  to  call  your  particular  attention  to 
several  little  items  in  the  local  management  of  the 
disease,  which  may  prove  of  great  service  to  you. 
There  is  nothing  of  importance  to  add  to  what  I have 
already  said  regarding  the  treatment  of  the  chancre 
itself,  but  some  of  the  secondary  lesions  require  atten- 
tion. Mucous  patches  sometimes  -give  great  annoy- 
ance, and  refuse  to  yield  to  purely  constitutional 
treatment,  becoming  sluggish  and  indolent.  In  such 
an  event,  the  pure  acid  'nitrate  of  mercury  will  be 
found  to  be  the  best  application.  Before  appl5’ing  it, 
the  lesion  should  be  dried  with  a piece  of  bibulous 
paper  or  absorbent  cotton.  The  surface  should  then 
be  thoroughly  cauterized,  after  which  it  should  be 
again  dried.  The  nitrate  of  silver  may  be  used  in  the 
same  manner.  Sometimes  cauterization  is  not  toler- 
ated, the  sore  becoming  . inflamed  and  irritable.  In 
such  cases  the  tr.  benzoin  co.  either  alone  or  in  com- 
bination wdth  the  mercuric  chloride  will  be  found 
most  effectual.  It  coats  the  lesion  with  a deposit  of 
the  gum  benzoin,  and  in  addition  to  its  mildly  stimu- 
lant and  antiseptic  action,  protects  the  surface  from 
irritation.  When  mucous  patches  hypertrophy,  and 
form  tubercles  or  condylomata,  an  application  of 
hydrarg.  bichlor.  in  collodion  in  a strength  of  four  to 
twenty  grains  to  the  ounce,  will  be  found  to  remove 
them  very  rapidly.  Calomel,  zinc  oxide,  salicylic 
acid  and  iodoform  are  also  all  quite  useful  applica- 
tions.* Washing  the  parts  in  salt  and  water  followed 


* Salicylic  acid  ointment  or  plaster  and  chrysarobin  are  Tery  useful 
applications  in  the  early  syphilides  and  syphilitic  psoriasis.  Mauriac 
recommends  the  following  formula  : 


01.  cadini. 


Ung.  Hydrarg.  j 
Vaselinee , 


-each  , 


partes  j 
partes  xv 


M. — To  be  used  by  inunction,  morning  and  evening,  for  syphilitic 
psoriasis  of  the  palms  and  soles. 


— 239  — 


by  the  application  of  calomel  is  also  of  service,  as 
nascent  bichloride  of  mercury  is  formed  and  acts  very 
powerfully  upon  the  lesions.  It  will  often  be  found 
that  very  obstinate  skin  lesions  will  improve  rapidly 
under  mercurial  fumigations,  after  all  other  rnethods 
of  treatment  have  proved  inefficacious.  Dr.  F.  B. 
Kane  described  in  the  Dublin  Journal  of  the  Medical 
Sciences  for  November,  1874,  an  apparatus  for  local 
fumigation  of  syphilitic  lesions,  which  is  sometimes 
useful.  The  Journal  in  question  contains  a good 
illustration  of  the  apparatus,  to  which  you  may  refer 
for  the  details  of  its  application.  I have  been  using 
sprays  of  bichloride  solution  and  iodoform  and  ether, 
with  good  success,  especially  in  pharyngeal  lesions. 
In  case  of  secondary  or  even  tertiary  lesions  upon  the 
face  which  are  non-ulcerative,  the  solution  of  bichloride 
in  collodion  will  be  found  to  remove  them  quite  rap- 
idly. Be  careful,  however,  not  to  cause  severe  blis- 
tering of  the  skin  by  too  powerful  or  too  frequent 
applications.  I find  that  a solution  of  the  bichloride 
in  the  compound  tincture  of  benzoin  is  even  better 
than  the  collodion  solution.  It  is  less  apt  to  blister, 
and  may  be  entrusted  to  the  patient  for  application. 
It  is,  however,  rather  disagreeable  in  that  it  discolors 
the  skin,  and  is  with  difficulty  removed.  The  oleate 
of  copper,  as  recommended  by  Dr,  Shoemaker  for 
freckles  and  other  pigmentary  lesion  of  the  skin, 
seems  to  act  well  in  removing  the  discolorations  left 
by  the  syphilides.  Soaps  containing  the  bichloride 
are  also  useful.  In  case  of  ecthymatous  or  rupial 
ulcerations,  frictions  with  the  oleate  of  mercury  are 
beneficial.  Gummy  ulceration,  especially  when  situ- 
ated in  the  mouth  or  pharynx,  may  be  best  treated  by 
the  application  of  benzoin,  for  although  iodoform  is 
also  quite  effectual,  it  is  far  more  unpleasant,  for  most 
people  do  not  like  to  have  such  an  odorous  applica- 
tion in  so  close  proximity  to  their  nasal  and  digestive 
organs. 

The  following  formulae  will  be  found  quite  effectual 
in  lesions  of  the  throat  and  nose  ; 


240  — 


lodoformi 

Camphorae aa  5 iii 

Morphiae gr.  iv 

Pulv.  acaciae 5 ii 

Ac.  tannici gr,  x 

Bismuthi  subuit 5 iv 

M.  Sig. — Use  with  powder  blower. 

lodinii  pur gr.  xx 

Kalii  iodii gr.  lx 

Ac.  carbolic! 5 ss 

Olei  eucalypti 5 i 

Boro-glyceridi 5 Hi 

Olei  menth.  pip mx 

Glycerin,  tannat.  q.  s.  ad 5 i 


M.  Sig. — Apply  with  probang  or  camel’s-hair 
pencil. 

There  is  one  complication  of  syphilis  which  merits 
special  mention  ; I refer  to  syphilitic  iritis;  In  this 
disease  synechiae  or  adhesions  form  ver}^  rapidly,  and 
treatment  must  be  correspondingly  vigorous.  Where 
possible,  the  responsibility  should  be  divided  with  a 
good  oculist.  The  patient  must  be  brought  under 
mercury  as  rapidly  as  possible.  Either  hypodermic 
injections  or  minute  doses  of  calomel  frequentl}'  re- 
peated are  excellent  methods.  Leeches  should  be 
applied  to  the  temporal  region,  and  cathartics  ad- 
ministered to  secure  the  benefits  of  derivation  and 
local  depletion.  Either  hot  or  cold  applications  ma}" 
prove  beneficial.  Most  important  of  all  is  dilatation 
of  the  pupil  by  atropine.  A solution  of  from  4 to  8 
grains  to  the  ounce  should  be  instilled  into  the  eye 
several  times  daily  until  dilatation  is  complete. 

We  sometimes  meet  with  cases  of  necrosis  of  the 
bones  in  various  situations  in  late  syphilis,  or,  more 
properly  speaking,  the  period  of  sequelas.  Tr}^  and 
determine  whether  the  osseous  troubles  are  due  to 
syphilis  or  to  mercury,  and  then  treat  them  upon  gen- 
eral principles.  Remember  that  tonics  are  alwa^^s 
indicated  in  these  cases,  and  that  the  iodides  are  our 
main  reliance,  mercury,  if  given  at  all,  being  indicated 


— 241  — 


only  in  tonic  doses.  The  following  case  is  a fair 
illustration  of  the  destruction  sometimes  produced  by 
necrosis  in  late  syphilis.  A young  man  of  thirty  was 
referred  to  me  by  his  physician,  for  a possible  opera- 
tion upon  the  naso-phar3’ngeal  cavity  for  the  removal 
of  dead  bone.  I found  the  palatal  and  nasal  bones 
entirely  destroj'ed,  and  that  destructive  ulceration 
had  already  attacked  the  vault  of  the  pharynx  and 
was  threatening  the  osseous  structures  at  the  base  of 
the  skull.  Mercurial  treatment  had  been  persisted  in 
for  the  entire  course  of  the  disease,  which  had  been 
contracted  nine  jmars  before.  I removed  a few  small 
scales  of  necrosed  bone,  which  were  partially  de- 
tached, and  put  the  patient  upon  tonics  and  increas- 
ing doses  of  the  iodide.  Improvement  was  quite 
rapid,  and  the  patient  w'as  sent  home  at  the  end  of 
six  weeks  in  comparatively  good  health.  As  a parting 
injunction  in  the  treatment  of  syphilis,  I wish  you  to 
remember  that  cleanliness  is  nowhere  productive  of 
better  results  than  in  this  disease.  The  Turkish  or 
Russian  bath  once  or  twice  weekly  has  an  excellent 
general  as  well  as  local  effect,  and  where  possible  to 
use  them,  recommend  them  all  to  your  patients. 
These  baths  are  such  a useful  adjunct  to  other  meth- 
ods of  treatment  of  syphilis  that  I wonder  at  the 
negligence  of  most  physicians  in  omitting  to  prescribe 
them.  They  have  several  effects  in  syphilis  wRich 
are  of  paramount  importance.  These  are  briefly : 

1.  Stimulation  of  the  nutrition  of  the  skin,  thus 
rendering  eruptions  less  likely  to  occur. 

2.  Elimination  of  peccant  materials  and  of  mer- 
cury itself,  thus  preventing  saturation  of  the  sj^stem 
with  the  drug,  and  assisting  the  system  in  throwing 
off  the  products  of  retrograde  metamorphosis  of 
syphilitic  neoplasia. 

3.  Increase  of  retograde  metamorphosis,  thus  has- 
tening resolution  of  syphilitic  deposits. 

4.  A general  tonic  effect. 

An  excellent  adjuvant  to  the  baths  is  the  use  of  hot 
water  internally  at  the  time  the  baths  are  taken.  This 


242  — 


prevents  the  otherwise  debilitating  effects  of  frequent 
baths,  and  in  addition  keeps  the  kidneys  in  active 
functional  condition.  Used  in  this  manner,  the 
Turkish  or  Russian  bath  will  often  accomplish  essen- 
tially the  same  end  as  the  treatment  in  vogue  at  the 
famous  Hot  Springs  of  Arkansas. 

In  very  obstinate  cases,  however,  a course  at  the 
Hot  Springs  will  sometimes  be  of  service  when  all 
other  means  fail.  When  a patient  goes  to  this  well- 
known  resort,  he  is  usually  willing  and  financially 
able  to  attend  strictly  to  treatment,  something  that  he 
will  seldom  do  at  home.  The  careful  attention  to 
treatment  and  diet,  the  cessation  of  all  bad  habits, 
and  the  change  of  climate,  probably  have  as  much  to 
do  with  the  excellent  results  sometimes  obtained  as 
any  curative  property  which  may  be  possessed  by  the 
waters.  Should  you  think  it  wise  to  advise  patients 
to  go  to  the  Hot  Springs,  be  sure  and  recommend 
them  to  some  reputable  physician  in  that  resort  or 
they  may  fall  among  the  Philistines ; they  certainly 
require  careful  supervision  at  the  hands  of  a compe- 
tent practitioner,  in  order  that  they  may  obtain  the 
best  results  from  their  sojourn  at  the  Springs.  There 
are  skillful  and  conscientious  practitioners  at  that 
famous  resort,  and  there  is  no  reason  why  your 
patients  should  not  be  put  in  the  right  way  to  find 
them,  rather  than  to  allow  them  to  take  their  chances. 


A LECTURE;  ON 

SEXUAL  PERVERSION,  SATYRIASIS  AND 
NYMPHOMANIA.! 


Gentlemen  : The  subject  of  sexual  perversion  {^Co?r- 

trare  Sexualempfindung),  although  a disagreeable  one 
for  discussion,  is  one  well  worthy  the  attention  of  the 
scientific  physician,  and  is  of  great  importance  in  its 
social,  medical  and  legal  relations^ 

The  subject  has  been  until  a recent  date  studied 
solely  from  the  standpoint  of  the  moralist,  and  from 
the  indisposition  of  the  scientific  physician  to  study 
the  subject,  the  unfortunate  class  of  individuals  who 
are  characterized  by  perverted  sexuality  have  been 
viewed  in  the  light  of  their  moral  responsibility  rather 
than  as  the  victims  of  a physical  and  incidentally  of  a 
mental  defect.  It  is  certainly  much  less  humiliating 

'Phila.  Med.  & Surg.  Rep.,  Sept.  7,  1889. 

“ In  a recent  article,  Dr.  J.  G.  Kiernan,  of  Chicago,  in  discuss- 
ing the  hypothetical  dependence  of  the  Whitechapel  murders  up- 
on sexual  perv'ersion,  says:  “The  present  subject  may  seem  to 

trench  on  the  ‘ prurient,’  which  in  medicine  does  not  exist,  since 
‘science,  like  fire,  purifies  everything,’  and  what  Macaulay  calls 
‘ the  mightiest  of  human  instincts  ’ is  too  intimately  related  to  the 
physical  basis  of  human  weal  and  woe  for  any  physician  prudishly 
to  ignore  any  of  its  phases.” 


244 


to  US  as  atoms  of  the  social  fabric  to  be  able  to  at- 
tribute the  degradation  of  these  poor  unfortunates  to 
a physical  cause,  than  to  a willful  viciousness  o\mr 
which  they  have,  or  ought  to  have,  volitional  control. 
Even  to  the  moralist  there  should  be  much  satisfac- 
tion in  the  thought  that  a large  class  of  sexual  per- 
verts are  physically  abnormal  rather  than  morally 
leprous.  It  is  often  difficult  to  draw  the  line  of  de- 
marcation between  physical  and  moral  perversion. 
Indeed,  the  one  is  so  often  dependent  upon  the  other 
that  it  is  doubtful  whether  it  were  wise  to  attempt  the 
distinction  in  many  instances.  But  this  does  not  af- 
fect the  cogency  of  the  argument  that  the  se.xual  per- 
vert is  generally  a physical  aberration — a lusus  nat- 
urcB. 

Krafft-Ebing'  expresses  himself  upon  this  point  as 
follows:  “In  former  years  I considered  ^c.r- 

ualeinpfindiuig  as  a result  of  neuro-ps3mhical  degenera- 
tion, and  I believe  this  view  is  warranted  b}^  more  re- 
cent investigations.  As  we  study  into  the  abnormal 
and  diseased  conditions  from  which  this  malady  re- 
sults, the  ideas  of  horror  and  criminality  connecced 
with  it  disappear,  and  there  arises  in  our  minds  the 
sense  of  duty  to  investigate  what  at  first  sight  seems 
so  repulsive,  and  to  distinguish,  it  may  be,  between  a 
perversion  of  natural  instincts  which  is  the  result  of 
disease,  and  the  criminal  offenses  of  a perverted  mind 
against  the  laws  of  m.orality  and  social  decencj'.  By 
so  doing  the  investigations  of  science  will  become  the 
means  of  rescuing  the  honor  and  re-establishing  the 
social  position  (sic)  of  manj^  an  unfortunate  whom 
unthinking  prejudice  and  ignorance  would  class 
among  depraved  criminals.  It  would  not  be  the  first 
time  that  science  has  rendered  a service  to  justice  and 
to  societ}^  by  teaching  that  what  seem  to  be  immoral 
conditions  and  actions  are  but  the  results  of  disease.” 

There  is  in  every  community  of  an}^  size  a colon}' of 


' Journ.  Psychiatry  and  Neurology,  Vol.  IX,  No.  4,  p.  505. 


245 


male  sexual  perverts;  they  are  usually  known  to  each 
other,  and  are  likely  to  congregate  together.  At  times 
they  operate  in  accordance  with  some  definite  and 
concerted  plan  in  quest  of  subjects  wherewith  to  grat- 
ify their  abnormal  sexual  impulses.  Often  they  are 
characterized  by  effeminacy  of  voice,  dress  and  man- 
ner. In  a general  way,  their  physique  is  apt  to  be  in- 
ferior— a defective  physical  make-up  being  quite  gen- 
eral among  them,  although  exceptions  to  this  rule  are 
numerous. 

Sexual  perversion  is  more  frequent  in  the  male; 
women  usually  fall  into  perverted  sexual  habits  for  the 
purpose  of  pandering  to  the  depraved  tastes  of  their 
patrons  rather  than  from  instinctive  impulses.  Ex- 
ceptions to  this  rule  are  occasionally  seen.  For  ex- 
ample, I know  of  an  instance  of  a woman  of  perfect 
physique,  who  is  not  a professional  prostitute,  but 
moves  in  good  society,  who  has  a fondness  for  women, 
being  never  attracted  to  men  for  the  purpose  of  ordi- 
nary sexual  indulgence,  but  for  perverted  methods. 
The  physician  rarely  has  his  attention  called  to  these 
things,  and  when  evidence  of  their  existence  is  placed 
before  him,  he  is  apt  to  receive  it  with  skepticism. 
He  regards  the  subject  as  something  verging  onMun- 
chausenism,  or,  if  the  matter  seem  at  all  credible,  he 
sets  it  aside  as  something  unholy  with  which  he  is  not 
or  shoidd  not  be  concerned.  It  is  indeed  not  to  be 
wondered  at  that  the  doctor,  who  sees  so  much  to 
disgust  him  with  the  human  animal,  should  be  reluc- 
tant to  add  to  his  store  of  contempt.  The  man  about 
town  is  very  often  an  fait  in  these  matters,  and  can 
give  very  valuable  information.  Indeed,  witnesses 
enough  can  be  found  to  convince  the  most  skeptical. 

Sexual  perversion  may  be  best  defined  in  a general 
way  as  the  possession  of  impulses  to  sexual  gratifica- 
tion in  an  abnormal  manner,  with  a partial  or  a com- 
plete apathy  toward  the  normal  method. 

The  affection  presents  itself  in  several  forms,  which 
maybe  tabulated  as  follows: 


Congenital  and  per-  | ^ 
haps  hereditary  J 
sexual  perver- 
sion. 1 


II. 


Acquired  sexual  per-  ^ 


Sexual  perversion  without  defect  of 
structure  of  sexual  organs. 

Sexual  perversion  with  defect  of  gen- 
ital structure,  e.  g.,  hermaphroditism. 
Sexual  perversion  with  obvious  defect 
of  cerebral  development,  e.  g.,  idiocy. 
Sexual  perversion  from  pregnancy,  the 
meno-pause,  ovarian  disease,  hysteria, 
etc. 

Sexual  perversion  from  acquired  cere- 
bral disease,  with  or  without  recog- 
nized insanity. 

Sexual  perversion  (?)  from  vice. 

Sexual  perversion  from  over  stimula- 
tion of  the  nerves  of  sexual  sensibility 
and  the  receptive  sexual  centers,  inci- 
dental to  sexual  excesses  and  mastur- 
bation. 


As  regards  the  clinical  manifestations  of  the  disease 
sexual  perverts  may  be  classified  as  : («)  Those  hav- 

ing a predilection  (affinity)  for  their  own  sex;  (^b) 
those  having  a predilection  for  abnormal  methods  of 
gratification  with  the  opposite  sex;  (r)  those  affected 
with  bestiality.  Instances  of  all  these  different  vari- 
eties have  been  observed. 


The  Precise  Causes  of  sexual  perversion  are  obscure. 
The  explanation  of  the  phenomenon  is  in  a general 
way  much  more  definite.  Just  as  we  may  have  varia- 
tions of  physical  form,  and  of  mental  attributes,  in  gen- 
eral, so  we  may  have  variations  and  perversions  of  that 
intangible  entity  : sexual  affinity.  In  some  cases,  per- 
haps, sexual  differentiation  has  been  imperfect,  and 
there  is  a reversion  of  type  ; as  Kiernan  remarks 
“The  original  bi-sexuality  of  the  ancestors  of  the 
race,  shown  in  the  rudimentary  female  organs  of  the 
male,  could  not  fail  to  occasion  functional,  if  not  or- 
ganic, reversions  when  mental  or  physical  manifesta- 
tions were  interfered  with  b}'  disease  or  congenital 
defect.  The  inhibitions  on  excessive  action  to  ac- 
complish a given  purpose,  which  the  race  has  acquired 
through  centuries  of  evolution,  being  removed,  the 


* Medical  Standard,  November,  1888. 


247 


animal  in  man  springs  to  the  surface.  Removal  of 
these  inhibitions  produces,  among  other  results,  sex- 
ual perversions.” 

Reasoning  back  to  cell  life  we  see  many  variations 
of  sexual  affinity  and  the  function  of  reproduction,  be- 
tween the  primal  segmentation  of  the  cell — the  lowest 
type  of  procreative  action — and  that  complete  and 
perfect  differentiation  of  the  sexes  which  requires  a 
definite  act  of  sexual  congress  as  a manifestation  of 
the  acme  of  sexual  affinity,  and  for  the  purpose  of 
reproduction.  The  variations  in  the  7}iethods  of  sexual 
gratification — or  to  attribute  it  to  instinct,  of  perpetuat- 
ing the  species — which  are  presented  to  the  students  of 
natural  history,  are  numerous  and  striking.  It  is  not 
my  intention,  however,  to  give  this  matter  more  than 
oassing  notice.  The  method  of  sexual  gratification — 
i.  e.,  procreation — of  fishes,  is  a curious  phenomenon. 
It  is  difficult  to  appreciate  the  sexual  gratification  in- 
volved in  the  deposition  of  the  milt  of  the  male  fish 
upon  the  spawn  of  the  female,  yet  that  the  so-called 
instinctive  act  of  the  male  is  unattended  by  gratifica- 
tion is  improbable.  Indeed,  it  is  an  argument  as  ap- 
plicable to  the  lower  animals  as  to  man,  that,  were 
the  act  of  procreation  divested  of  its  pleasurable  fea- 
tures, the  species  would  speedily  become  extinct;  for 
the  act  of  procreation  per  se  is  possessed  of  no  features 
of  attractiveness,  but  of  many  that  are  repulsive  and 
in  themselves  productive  of  discomfort. 

It  is  puzzling  to  the  healthy  man  and  woman,  to 
understand  how  the  practices  of  the  sexual  pervert 
can  afford  gratification.  If  considered  in  the  light  of 
reversion  of  type,  however,  the  subject  is  much  less 
perplexing.  That  mal-development,  or  arrested  de- 
velopment, of  the  sexual  organs  should  be  associated 
with  sexual  perversion  is  not  at  all  surprising  ; and 
the  more  nearly  the  individual  approximates  the  type 
of  foetal  development  which  exists  prior  to  the  com- 
mencement of  sexual  differentiation,  the  more  marked 
is  the  aberrance  of  sexuality. 


248 


There  is  one  element  in  the  study  of  sexual  perversion 
that  deserves  especial  attention.  It  is  probable  that 
few  bodily  attributes  are  more  readily  transmitted  to 
posterity  than  peculiarities  of  sexual  ph5?siology.  The 
offspring  of  the  abnormally  carnal  individual  is  likely 
to  be  possessed  of  the  same  inordinate  sexual  appe- 
tite that  characterizes  the  parent.  The  child  of  vice 
has  within  it,  in  many  instances,  the  germ  of  vicious 
impulse,  and  no  purifying  influence  can  save  it  from 
following  its  own  inherent  inclinations.  Men  and 
women  who  seek,  from  mere  satiet}y  variations  of  the 
normal  method  of  sexual  gratification,  stamp  their 
nervous  systems  with  a malign  influence  which  in  the 
next  generation  may  present  itself  as  true  sexual  per- 
version. Acquired  sexual  perversion  in  one  genera- 
tion may  be  a true  constitutional  and  irradicable  vice 
in  the  next,  and  this  independently  of  gross  physical 
abberations.  Carelessness  on  the  part  of  parents  is 
responsible  for  some  cases  of  acquired  sexual  perver- 
sion. Boys  who  are  allowed  to  associate  intimatel}', 
are  apt  to  turn  their  inventive  genius  to  account  b}’ 
inventing  novel  means  of  sexual  stimulation,  with  the 
result  of  ever  after  diminishing  the  natural  sexual 
appetite.  Any  powerful  impression  made  upon  the 
sexual  system  at  or  near  puberty,  when  the  sexual 
apparatus  is  just  maturing  and  ver}^  active,  although 
as  yet  weak  and  impressionable,  is  apt  to  leave  an 
imprint  in  the  form  of  sexual  peculiarities  that  will 
haunt  the  patient  throughout  his  after  life.  Sexual 
congress  at  an  early  period,  often  leaves  its  impres- 
sion in  a similar  manner.  Many  an  individual  has 
had  reason  to  regret  the  indulgences  of  his  5’outh  be- 
cause of  its  moral  effect  upon  his  after  life.  The  im- 
pression made  upon  him  in  the  height  of  his  3’outhful 
sensibility  is  never  eradicated,  but  remains  in  his 
memory  as  his  ideal  of  sexual  matters;  for — if  5'ou 
will  pardon  the  metaphor — there  is  a phj'sical  as  well 
as  an  intellectual  memor}'.  As  he  grows  older  and 
less  impressionable,  he  seeks  vainl}'  for  an  experience 


249 


similar  to  that  of  his  youth,  and  so  joins  the  ranks  of 
the  sexual  monomaniacs,  who  vainly  chase  the  Will- 
o’-the-wisp  : sexual  gratification,  all  their  lives.  Vari- 
ations of  circumstance  may  determine  sexual  perver- 
sion rather  than  abnormally  powerful  desire.  Let  the 
physician  who  has  the  confidence  of  his  patients  in- 
quire into  this  matter,  and  he  will  be  surprised  at  the 
result.  Only  a short  time  since,  one  of  my  patients, 
a man  of  exceptional  intellect,  volunteered  a similar 
explanation  for  his  own  excesses.  Satiety  also  brings 
in  its  train  a deterioration  of  normal  sexual  sensibility, 
with  an  increase,  if  anything,  in  the  sexual  appetite. 
As  a result,  the  deluded  and  unfortunate  being  seeks 
for  new  and  varied  means  of  gratification,  often  de- 
grading in  the  extreme.  Add  to  this  condition,  intem- 
perance or  disease,  and  the  individual  may  bepome 
the  lowest  type  of  sexual  pervert.  As  Hammond  con- 
cisely puts  it,  regarding  one  of  the  most  disgusting 
forms  of  sexual  perversion:  “Pederasty  is  generally 
a vice  resorted  to  by  debauchees  who  exhaust  the  re- 
sources of  the  normal  stimulus  of  the  sexual  act,  and 
who  for  a while  find  in  this  new  procedure  the  pleasure 
which  they  can  no  longer  obtain  from  intercourse 
with  women.” 

When  the  differentiation  of  sex  is  complete  from  a 
gross  physical  standpoint,  it  is  still  possible  that  the 
receptive  and  generative  centers  of  sexual  sensibility 
may  fail  to  become  perfectly  differentiated.  The  re- 
sult under  such  circumstances  might  be,  upon  the  one 
hand,  sexual  apathy,  and  upon  the  other,  an  approxi- 
mation to  the  female  or  male  type,  as  the  case  may 
be.  Such  a failure  of  development  and  imperfect  dif- 
ferentiation of  structure,  would  necessarily  be  too 
occult  for  discovery  by  any  physical  means  at  our 
command.  It  is,  however,  but  too  readily  recognized 
by  its  results. 

There  exists  in  every  great  city  so  large  a number 
of  sexual  perverts,  that  seemingly  their  depraved 
tastes  have  been  commercially  appreciated  by  the 


250 


de7ni-monde.  This  has  resulted  in  the  formation  of 
establishments  whose  principal  business  it  is  to  cater  to 
the  perverted  sexual  tastes  of  a numerous  class  of 
patrons.  Were  the  names  and  social  positions  of 
these  patrons  made  public  in  the  case  of  our  own 
city,  society  would  be  regaled  with  something  fully  as 
disgusting,  and  coming  much  nearer  home,  than  the 
Pall  Mall  Gazette  exposure.* 

The  individuals  alluded  to  w’ould  undoubtedly  re- 
sent the  appellation  of  “sexual  pervert;”  bur,  never- 
theless, in  many  instances  they  present  the  disease  in 
its  most  inexcusable  form  : that  from  vicious  impulse. 
Personally,  I fail  to  see  any  difference,  from  a moral 
standpoint,  between  the  individual  who  is  gratified 
sexually  only  by  oral  masturbation  performed  b}'  the 
opposite  sex,  and  those  unfortunate  mortals  whose 
passions  can  be  gratified  only  by  performing  the  active 
role  in  the  same  disgusting  performance.  One  is  to 
be  pitied  for  his  constitutional  fault ; the  other  to  be 
despised  for  his  deliberately  acquired  debasement. 
In  the  case  of  the  professional  prostitute  who  panders 
to  the  depraved  sexual  tastes  of  certain  male  speci- 
mens of  the  genus  homo,  she  has,  at  least,  the  question- 
able excuse  of  commercial  instinct,  and  in  some 
cases  the  more  valid  one  of  essential  sexual  perver- 
sion. These  excuses  the  majority  of  her  patrons  cer- 
tainly do  not  have. 

An  interesting  theory,  bearing  upon  the  question  of 
sexual  perversion  in  its  relations  to  evolutionary  re- 
version, is  advanced  by  Professor  S.  V.  Clevenger.** 
This  is  well  worthy  of  repetition  and  I will  therefore 
quote  it  verbatum  : “A  paper  on  Researches  into  the 


* Since  the  above  was  written  the  world  has  been  regaled  with 
the  exposure  of  an  establishment  in  London  patronized  by  the 
aristocracy,  which  was  devoted  to  the  procurement  of  young  boys 
for  the  purpose  of  passive  pederasty.  I have  also  obtained  posi- 
tive knowledge  of  a physician  in  this  city  who  has  presented  dis- 
gusting manifestations  of  sexual  perversion  to  his  female  patients. 

“ Physiology  and  Psychology,  1885. 


251 


Life  History  of  the  Monads,  by  W.  H.  Dallinger,  F. 
R.  M.  S.,  and  J.  Drysdale,  M.  D.,  was  read  before  the 
Royal  Microscopical  Society,  Dec.  3,  1873,  wherein 
fission  of  the  monad  was  described  as  being  preceded 
by  the  absorption  of  one  form  by  another.  One  monad 
would  fix  on  the  sarcode  of  another,  and  the  substance 
of  the  lesser  or  under  one  would  pass  into  the  upper 
one.  In  about  two  hours  the  merest  trace' of  the 
lower  one  was  left,  and  in  four  hours  fission  and  mul- 
tiplication of  the  larger  monad  began.  A full  descrip- 
tion of  this  interesting  phenomenon  may  be  found  in 
the  Monthly  Microscopical  Journal  (London),  for  Octo- 
ber, 1877.  Professor  Leidy  has  asserted  that  the 
amceba  is  a cannibal,  whereupon  Mr.  Michels,  in  the 
American  Journal  of  Microscopy,  Jul3^  1877,  calls  atten- 
tion to  Dallinger  and  Drj'sdale’s  contribution,  and 
draws  therefrom  the  inference  that  each  cannibalistic 
act  of  the  amoeba  is  a reproductive,  or  copulative  one, 
if  the  term  is  admissible.  The  editor  (Di.  Henry 
Lawson)  of  the  English  journal  agrees  with  Michels.” 
“Among  the  numerous  speculations  upon  the  origin 
of  the  sexual  appetite,  such  as  Maudsley’s  altruistic 
conclusion,  which  always  seemed  to  me  to  be  far- 
fetched, I have  encountered  none  that  referred  its  de- 
rivation to  hunger.  At  first  glance  such  a suggestion 
seems  ludicrous  enough,  but  a little  consideration  will 
show  that  in  thus  fusing  two  desires,  we  have  still  to 
get  at  the  meaning  and  derivation  of  the  primary  one, 
desire  for  food.  The  cannibalistic  amoeba  may,  as  Dal- 
linger’s  monad  certainly  does,  impregnate  itself  by  eat- 
ing one  of  its  own  kind,  and  we  have  innumerable  in- 
stances, among  algae  and  protozoa,  of  this  sexual  fusion 
appearing  very  much  like  ingestion.  Crabs  have  been 
seen  to  confuse  the  two  desires  by  actually  eating  por- 
tions of  each  other  while  copulating  ; and  in  a recent 
number  of  the  Scie^itific  America7i,  a Texan  details  the 
mantis  religiosa  female  eating  off  the  head  of  the  male 
mantis  during  conjugation.  Some  of  the  female  arach- 
nidce  find  it  necessary  to  finish  the  marital  repast  by 


252 


devouring  the  male,  who  tries  to  scamper  away  from 
his  fate.  The  bitings  and  even  the  embrace  of  the 
higher  animals  appears  to  have  reference  to  this  deri- 
vation. It  is  a physiological  fact  that  association  oft- 
en transfers  an  instinct  in  an  apparently  outrageous 
manner.  With  quadrapeds  it  is  most  clearly  olfac- 
tion that  is  most  related  to  sexual  desire  and  its  re- 
flexes; but  not  so  in  man.  Terrier  diligently  searches 
the  region  of  the  temporal  lobe  near  its  connection 
with  the  olfactory  nerve  for  the  seat  of  sexuality;  but 
with  the  diminished  importance  of  the  smelling  sense 
in  man,  the  faculty  of  sight  has  grown  to  vicariate  ol- 
faction; certainly  the  ‘lust  of  the  eyes'  is  greater 
than  that  of  other  special  sense  organs  among  Bi- 
mana. 

“ In  all  animal  life  multiplication  proceeds  from 
growth,  and  until  a certain  stage  of  growth,  puberty, 
is  reached,  reproduction  does  not  occur.  The  com- 
plementary nature  of  growth  and  reproduction  is  ob- 
servable in  the  large  size  obtained  by  some  animals 
after  castration.  Could  we  stop  the  division  of  an 
amoeba,  a comparable  increase  in  size  would  be  ef- 
fected. The  grotesqueness  of  these  views  is  due  to 
their  novelty,  not  to  their  being  unjustiflable.  While  it 
must  thus  seem  apparent  that  a primeval  origin  for  both 
ingestive  and  sexual  desire  existed,  and  that  each  is  a 
true  hunger,  the  one  being  repressible,  and  in  higher 
animal  life  being  subjected  to  more  control  than  the 
other,  the  question  then  presents  itself:  \Miat  is  hun- 
ger ? It  requires  but  little  reflection  to  convince  us  of 
its  potency  in  determining  the  destiii)'  of  nations  and 
individuals,  and  what  a stimulus  it  is  in  animated 
creation.  It  seems  likely  that  it  has  its  origin  in  the 
atomic  affinities  of  inanimate  nature,  a view  monistic 
enough  to  please  Haeckel  and  T5’ndall.” 

Dr.  Spitzka,"  in  commenting  on  the  foregoing,  says: 
“There  are  some  observations  made  b)^  alienists 


' Science,  June  25,  1881. 


253 


which  strongly  tend  to  confirm  Dr.  Clevenger’s  the- 
ory. It  is  well  known  that,  under  pathological  cir- 
cumstances, relations,  obliterated  in  higher  develop- 
ment and  absent  in  health,  return  and  simulate  con- 
ditions found  in  lower  and  even  in  primitive  forms. 
An  instance  of  this  is  the  pica  or  morbid  appetite  of 
pregnant  women  and  li3'sterical  girls  for  chalk,  slate- 
pencils  and  other  articles  of  an  earthy  nature.  To 
some  extent  this  has  been  claimed  to  constitute  a 
sort  of  reversion  to  the  oviparous  ancestry,  which, 
like  the  birds  of  our  day,  sought  the  calcerous  mate- 
rial required  for  the  shell  structure  in  their  food. 
There  are  forms  of  mental  perversion  properly  classed 
under  the  head  of  the  degenerative  mental  states  with 
which  a close  relation  between  the  hunger  appetite 
and  sexual  appetite  becomes  manifest.  Under  the 
heading  ‘ Wallusi,  Mordhist,  Anthropophagie,’  Krafft- 
Ebing  describes  a form  of  sexual  perversion  where  the 
sufferer  fails  to  find  gratification  unless  he  or  she  can 
bite,  eat,  murder  or  mutilate  the  mate.  He  refers  to 
the  old  Hindoo  myth:  Civa  and  Durga,  as  showing 
that  such  observations  in  the  sexual  sphere  were  not 
unknown  to  the  ancient  races.  He  gives  an  instance 
where,  after  the  act,  the  ravisher  butchered  his  victim 
and  would  have  eaten  a piece  of  the  viscera;  another 
where  the  criminal  drank  the  blood  and  ate  the  heart; 
still  another  where  certain  parts  of  the  body  were 
cooked  and  eaten.”  ^ Nature  (London),  commenting 
on  my  article,  quotes  Ovid:  “ Mutieres  in  coitu  non- 

ne7iique  genas  cervicenique  maris  mordiuit."  Illustra- 
tions of  the  varying  types  of  sexual  perversion  are  of 
late  years  finding  their  way  into  literature.  A very 


' Ueber  gewisse  Anomalien  des  Geschlechtstriebes.  Von 
Krafft-Ebing,  Archiv.  fur  Psychiatre,  VII.  It  is  unnecessary  to 
call  attention  to  the  logic  of  Dr.  Kiernan’s  deductions  from  the 
above  as  applied  to  the  Whitechapel  horrors.  (“  Sexual  Perver- 
sion and  the  Whitechapel  Murders,”  Dr.  J.  G.  Kiernan,  JMedical 
Standard,  November,  1888.) 


254 


interesting  series  of  cases  is  related  by  Professor  von 
Krafft-Ebing.  Journal  of  Neurology  and  Psychiatry. 

Hammond,  quoting  from  Tardieu,*  chronicles  the 
following  interesting  points  with  regard  to  one  form 
of  sexual  perversion:  “ I do  not  pretend  to  explain 

that  which  is  incomprehensible,  and  thus  to  penetrate 
into  the  causes  of  pederasty.  We  can  nevertheless 
ask  if  there  is  not  something  else  in  this  vice  than  a 
moral  perversion,  than  one  of  the  forms  of  psycliopathia 
sexualis,  of  which  Kaan  has  traced  the  history.  Un- 
bridled debauchery,  exhausted  sensuality,  can  alone 
account  for  pederastic  habits  as  they  exist  in  married 
men  and  fathers  of  families,  and  reconcile  with  a de- 
sire for  women  the  existence  of  these  impulses  to  un- 
natural acts.  We  can  form  some  idea  on  the  subject 
from  a perusal  of  the  writings  of  pederasts  containing 
the  expression  of  their  depraved  passions.  Casper 
has  had  in  his  possession  a journal  in  which  a man, 
member  of  an  old  family,  had  recorded,  day  by  day, 
and  for  several  years,  his  adventures,  his  passions, 
and  his  feelings.  In  this  diary  he  had,  with  unex- 
ampled cynicism,  avowed  his  shameful  habits,which 
had  extended  through  more  than  thirty  years,  and 
which  had  succeeded  to  an  ardent  love  for  the  oth- 
er sex.  He  had  been  initiated  into  these  new  pleas- 
ures by  a procuress,  and  the  description  which  he 
gives  of  his  feelings  is  startling  in  its  intensit}’.  The 
pen  refuses  to  write  of  the  orgies  depicted  in  this 
journal,  or  to  repeat  the  names  which  he  gave  to  the 
objects  of  his  love.” 

“ I have  had  frequent  occasion  to  read  the  corre- 
spondence of  known  pederasts,  and  have  found  them 
applying  to  each  other,  under  the  forms  of  the  most 
passionate  language,  idealistic  names  which  legiti- 
mately belong  to  the  diction  of  the  truest  and  most 
ardent  love.  But  it  is  difficult  not  to  admit  the  ex- 
istence in  some  cases  of  a real  pathological  alteration 


“ Sur  les  attentats  aux  moeurs.  Paris,  18j8,  p.  125. 


255 


of  the  moral  faculties.  When  we  witness  the  pro- 
found degradation,  the  revolting  salacity  of  the  indi- 
viduals who  seek  for  and  admit  to  their  disgusted  fa- 
vors men  who  are  gifted  both  with  education  and  for- 
tune, we  might  well  be  tempted  to  think  that  their 
sensations  and  reason  are  altered;  but  we  can  enter- 
tain no  doubt  on  the  subject,  when  we  call  to  mind 
facts  such  as  those  I have  had  related  to  me  by  a 
magistrate,  who  has  displayed  both  ability  and  ener- 
gy in  the  pursuit  of  pederasts.  One  of  these  men, 
who  had  fallen  from  a high  position  to  one  of  the  low- 
est depravity,  gathered  about  him  the  dirty  children 
of  the  streets,  knelt  before  them  and  kissed  their  feet 
with  passionate  submission  before  asking  them  to 
yield  themselves  to  his  infamous  propositions.  Anoth- 
er 'experienced  singularly  voluptuous  sensations  by 
having  a vile  wretch  administer  violent  kicks  on  his 
gluteal  region.  What  other  idea  can  we  entertain  of 
such  horrors  than  that  those  guilty  of  them  are  actu- 
ated by  the  most  pitiable  and  shameful  insanity?” 
Some  of  the  manifestations  of  sexual  perversion, 
quoted  by  various  authorities,  are  very  extraordinar}^, 
and  it  is  difficult  to  associate  them  with  titillations  of 
the  sexual  sensibility.  Perhaps  the  most  familiar  of 
these  cases  is  that  of  Sprague,  who  was  committed 
in  Brooklyn  a number  of  years  ago  for  highway  rob- 
bery. ^ It  is  unnecessary  to  present  this  case  in  detail, 
but  an  outline  of  it  may  prove  interesting.  Sprague 
was  arrested  immediately  after  having  assaulted  a 
young  lady  by  throwing  her  down  violently,  removing 
one  of  her  shoes  and  running  away  with  it.  He  made 
no  attempt  to  steal  anything  else,  although  she  had 
on  valuable  jewelry.  When  the  trial  came  on,  insan- 
ity was  alleged  as  a defense.  Numerous  witnesses, 
the  principal  of  whom  was  the  father  of  the  defendant, 
a clergyman  of  the  highest  respectability,  testified  to 
the  erratic  conduct  of  the  prisoner.  A family  history 


'Beck:  Medical  Jurisprudence,  Vol.  I,  1860,  p.  732. 


256 


was  elicited  which  bore  most  pertinently  upon 
Sprague’s  case.  His  grandfather,  grandmother,  great- 
grand-uncle,  three  great-aunts,  and  a cousin  having 
been  insane.  He  had  himself  in  his  youth  received 
numerous  blows  and  falls  upon  the  head,  and  within 
a year  from  the  last  head  injury  he  had  developed  se- 
vere headaches,  associated  with  which  his  friends 
noticed  a bulging  of  the  eyes.  About  this  time  the 
prisoner  developed  a fondness  for  stealing  and  hiding 
the  shoes  of  females  about  the  house,  and  it  was  found 
necessary  by  his  relatives  and  the  female  domestics 
to  carefully  conceal  or  lock  up  their  shoes  to  prevent 
his  abstracting  them.  Upon  investigation  it  was  dis 
covered  that  the  act  of  stealing  or  handling  the  shoes 
produced  in  him  sexual  gratification.” 

Wharton*  several  years  ago  chronicled  a most  pe- 
culiar case  of  sexual  perversion.  In  this  instance  the 
morbid  sexual  desire  impelled  the  individual  to  as- 
sault young  girls  upon  the  streets  of  Leipzig  by  grasp- 
ing them  and  plunging  a small  lancet  into  their  arms 
above  the  elbow.  The  fact  was  developed  after  his 
arrest  that  these  peculiar  acts  of  assault  were  accom- 
panied by  seminal  emissions.  This  authentic  case 
gives  a vivid  coloring  to  the  rational  hypothesis  that 
the  now  famous  Whitechapel  assassin  is  a sexual  per- 
vert, a theory  which  Kiernan  in  particular  has  sup- 
ported, and  which  I believe  has  suggested  itself  to 
the  minds  of  the  majority  of  medical  men  who  have 
given  the  murders  even  slight  consideration. 

Many  cases  of  sexual  perversion  manifest  them- 
selves only  under  the  influence  of  disease  or  of  drunk- 
enness. Ovarian  irritation,  and  those  more  obscure 
cases  of  h3^steria  in  women  which  we  are  unable  to 
trace  to  a definite  physical  cause,  are  frequenth'  as- 
sociated with  sexual  perversion.  The  ph}’siological(?) 
disturbance  incidental  to  pregnancj'^  is,  in  certain  neu- 
rotic patients,  productive  of  similar  aberration. 


'A  Treatise  on  Mental  Unsoundness,  etc.,  Philadelphia,  1873. 


257 


Whether  the  influence  of  liquor  obtunds  the  moral 
faculties,  or  develops  an  inherent  defect  of  sexual 
physiology  in  any  given  case,  is  of  course  difficult  to 
determine.  I know  of  an  individual  who  conducts 
himself  with  perfect  propriety  when  sober,  and  who  is 
a man  of  exceptional  intellect,  but  who,  when  under 
the  influence  of  alcohol,  is  too  low  for  consort  with 
the  human  species. 

The  association  of  sexual  perversion  with  malform- 
ations of  the  sexual  organs  with  or  without  associated 
close  approximation  to  the  general  phj^sique  of  the 
opposite  sex,  male  or  female,  as  the  case  may  be,  is 
certainly  not  surprising.  I have  met,  in  my  own  ex- 
perience, with  a most  peculiar  illustration  of  this  form 
of  sexual  perversion,  in  the  form  of  a young  mulatto 
hypospadiac.  This  man  had  marked  hypospadias, 
and  had,  it  seems,  an  affinity  for  women,  as  illustrated 
by  the  fact  that  he  contracted  a gonorrhoea  in  the  nor- 
mal manner.  That  he  also  had  a predilection  for  the 
passive  role  in  the  act  of  copulation  was  demonstrated 
by  the  fact  that  a number  of  young  lads,  ranging  from 
ten  to  seventeen  years  of  age,  who  lived  in  the  neigh- 
borhood in  which  the  spurious  hermaphrodite  was 
employed  in  the  capacity  of  cook,  contracted  from 
him  typical  gonorrhoea,  for  which  several  of  them 
came  under  my  care. 

A peculiar  case  was  recently  reported  to  the  Chi- 
cago Medical  Society  by  Dr.  A.  R.  Reynolds,  of  this 
city,  of  a man  who  had  a love  affair  with  a woman 
whose  right  lower  extremity  had  been  amputated  at 
the  thigh,  and  became  so  much  attached  to  her  that 
he  was  afterward  impotent  with  perfectly  formed 
women,  it  being  necessary  for  him  to  secure  females 
who  had  undergone  mutilation  similar  to  that  of  his 
former  attachment  in  order  that  he  might  be  sexually 
gratified.^  A peculiar  phase  of  sexual  perversion  is 
occasionally  seen  among  masturbators,  male  and  fe- 


^ Western  ^ledical  Reporter,  Nov.,  1888. 


258 


male.  The  individuals  suffering  from  this  have  a pe- 
culiar predilection  for  titillating  the  sexual  organs  in 
the  most  outlandish  fashion.  Such  patients  are  in 
many  instances  particularly  fond  of  introducing  for- 
eign bodies  of  various  kinds  into  the  uretha  and  thus 
gratifying  their  sexual  desires.  Such  cases  occur 
even  among  persons  who  have  opportunities  for  nor- 
mal gratification.  Thus  an  interesting  case  is  re- 
ported by  Poulet ' of  a married  woman,  the  mother  of 
three  children,  who  failed  to  receive  gratification  from 
ordinary  intercourse,  and  practiced  masturbation  with 
a blunt  piece  of  wood  fastened  to  a wire.  Her  unfortu- 
nate failing  was  exposed  through  the  slipping  of  the 
foreign  body  from  her  grasp  into  the  bladder.  Kier- 
nan  reports  a somewhat  similar  case  of  an  insane  girl 
who  was  admitted  into  his  service  at  the  Cook  Countj' 
Insane  Asylum.  In  this  instance  the  ph}'sical  appear- 
ance of  the  sexual  organs  and  anus  led  to  a suspicion 
of  pederasty  which  was  confirmed  upon  investigation.” 

I have  already  directed  attention  to  forms  of 
sexual  perversion  which  do  not  conform  to  Westphal’s 
definition  of  Cotitrare  Sextialempfijidung,  which  implies 
a sexual  predilection  on  the  part  of  an  individual  for 
those  of  his  or  her  own  sex  with  an  inversion  for  se.x- 
ual  intimacy  with  those  of  the  opposite  sex.  In  my 
opinion  certain  other  cases  of  disease,  the  principal 
manifestation  of  which  is  excessive  sexual  desire,  are 
really  forms  of  sexual  perversion.  Such  cases  are 
often  met  with  in  both  the  male  and  the  female. 

Satyriasis  is  a disease  that  occurs  in  the  male,  with 
or  without  insanity,  the  principal  manifestation  of 
which  is  an  abnormally  excessive  and  unreasonable 
sexual  desire.  It  is  not  a frequent  disease  as  brought 
to  the  attention  of  the  ph5^sician,  probabl}'  because 
the  opportunities  for  gratification  of  the  male  are  rela- 
tively numerous. 


' Foreign  Bodies." 

^ IVesicrn  Medical  Reporter,  Nov.,  1888. 


259 


The  disease  consists  of  a constaiit  desire,  attended 
with  vigorous  erections,  which  no  amount  of  sex- 
ual intercourse  in  some  instances  will  gratify.  It  has 
been  termed  “erotic  delirium,”  and  it  may  or  may  not 
be  due  to  coarse  disease  of  the  brain.  In  the  worst 
cases  of  the  disease  the  unfortunate  individual  maybe 
the  subject  of  mania  and  delirium  of  a violent'form. 
Acton'  relates  to  the  case  of  an  old  man,  suffering 
from  satyriasis,  whose  desire  was  so  extreme  that  he 
would  masturbate  whenever  he  was  brought  in  the 
presence  of  women.  After  his  death  a small  tumor 
was  found  in  the  pons  varolii. 

Shocks  and  injuries  involving  the  cerebellum  are 
peculiarly  apt  to  be  followed  by  persistent  erections. 
This  phenomenon  has  been  noticed  in  connection  with 
executions  by  hanging.  Injuries  of  the  spinal  cord, 
although  in  the  majority  of  instances  inhibiting  the 
sexual  function  by  producing  complete  paralysis  of 
that  portion  of  the  cord  which  seems  to  bear  an  inti- 
mate relation  to  sexual  sensibility,  produce  in  some 
instances  from  irritation  of  the  same  nervous  struct- 
ure, persistent  erection.  Cases  of  this  kind  are  re- 
lated by  Lallemand.'  The  following  case  is  one  which 
has  been  most  frequently  quoted: 

“This  man  was  a soldier,  who,  in  climbing  over  the 
walls  of  the  garrison,  fell  upon  his  sacrum.  Following 
this  injury  he  became  paraplegic  and  suffered  with  per- 
sistent priapism.  This  lasted  for  some  time,  and  could 
not  be  relieved  by  intercourse.  All  pleasurable  sensa- 
tions and  the  power  of  ejaculation  were  destroyed,  al- 
though sexual  desire  was  very  ardent.  During  sleep, 
however,  the  unfortunate  subject  had  lascivious  dreams, 
accompanied  by  slight  sensation  and  ejaculation.” 
The  causes  of  satyriasis,  as  enumerated  by  different 
authorities,  are  : masturbation,  diseases  of  the  brain, 
particularly  those  affecting  the  cerebellum,  injuries 


’On  the  Reproductive  Organs, 
^ On  Spermatorrhoea. 


26o 


and  diseases  of  the  spinal  cord,  sexual  excesses  and 
the  administration  of  poisonous  doses  of  cantharides. 
Prolonged  continuance  is  another  rare  and  dubious 
cause  to  which  satyriasis  has  been  ascribed. 

J.  W.  Howe,^  quoting  from  Blandet,  describes  a 
case  of  this  kind.  The  patient  was  an  earnest,  hard- 
working and  zealous  missionary.  He  was  unfortunate 
in  the  possession  of  an  intensely  passionate  nature, 
although  he  had  gratified  himself  in  a vicious  manner. 
So  intense  w'as  his  excitement  in  the  presence  of 
women  that  it  became  necessary  to  seclude  himself 
from  them  as  far  as  possible.  This  plan  proved  a 
failure,  for  he  became  so  much  worse  that  he  suffered 
from  satyriasis  in  an  extreme  degree.  A cure  was  fi- 
nally accomplished  by  the  normal  indulgence  of  his 
passion. 

The  mild  form  of  excessive  sexual  desire  called  pri- 
apism, may  be  due  to  local  irritation.  In  some 
instances  such  irritation  will  produce  severe  priapism 
without  sexual  desire.  I have  at  present  under  my 
charge  a gentleman  who  is  suffering  in  this  manner. 
He  is  about  50  years  of  age,  and  has  been  somewdiat 
dissipated  and  a high  liver,  as  a consequence  of  which 
he  has  gout  in  an  extreme  degree.  He  has  suffered 
for  several  jmars  from  vesical  irritation,  attributed  by 
him  to  stricture  of  long  standing.  The  urethra  on 
examination  presents  no  abnormalit}' ; the  urine  is 
highly  concentrated  and  strongl}^  acid.  As  soon  as 
the  patient  retires  for  the  night,  he  begins  to  be 
troubled  wdth  severe  erections,  which  are  so  marked 
as  to  be  quite  painful,  and  which  persist  during  the 
entire  night.  Sexual  intercourse  gives  no  relief.  I 
can  only  attribute  this  case  to  sexual  hyperaesthesia, 
incidental  to  long  continued  gout  and  irritation  of  the 
genito-urinar}'  tract.  This  does  not  manifest  itself 
during  the  daytime,  but  during  the  night ; when,  as 
is  well  known,  the  spinal  cord  is  relativel}’  h5'peraemic 


Excessive  Venery. 


26i 


and  in  a condition  of  increased  functional  activity. 
The  same  explanation  holds  good  here  that  prevails 
in  nocturnal  emissions. 

Nymphomania  (erotomania,  furor  uterinus)  is  a dis- 
ease analogous  to  satyriasis,  occurring  in  the  female. 
It  is  characterized  by  excessive  and  inordinate  sexual 
desire,  and  often  by  the  most  pronounced  lewdness 
and  vulgarity  of  speech  and  action.  In  the  most  se- 
ere  forms,  it  is  apt  to  be  associated  with,  and  de- 
pendent upon,  other  forms  of  insanity,  with  or  with- 
out gross  brain  disease.  In  some  instances  the 
disease  is  a reflex  manifestation  of  irritative  affections 
of  the  sexual  apparatus.  Thus,  ovarian  and  uterine 
diseases  are  apt  to  be  associated  with  it.  Any  irrita- 
tion about  the  external  genital  organs  in  a female  of 
hysterical  temperament  may  produce  the  affection  ; 
all  that  is  necessary  being  a nervous  and  excitable 
state  of  the  nervous  system,  a passionate  disposition, 
and  the  existence  of  local  irritation  of  the  sensitive 
sexual  apparatus.  Some  of  the  recorded  cases  of 
nymphomania  are  very  pitiful.  It  has  been  known 
to  be  associated  with  the  cerebral  distuabance  inci- 
dental to  pulmonary  consumption.  Thus,  a case  has 
been  recorded  of  a woman  who,  in  the  last  stages  of 
this  disease,  exhibited  the  most  inordinate  sexual 
desire,  and  but  a short  time  before  her  death  impor- 
tuned her  husband  to  have  intercourse  with  her. 

The  association  of  hysteria  with  this  unfortunate 
condition  of  the  mind  and  sexual  organs  is  one  with 
which  nearly  every  gynecologist  of  experience  is  per- 
fectly familiar.  Nymphomania  is  also  known  to  occur 
as  a result  of  masturbation  and  sexual  excess.  In 
women  of  a highly  erethistic  temperament,  it  has  been 
developed  as  a consequence  of  sudden  cessation  of 
the  normal  method  of  sexual  indulgence. 

A knowledge  of  sexual  matters  is  by  no  means  nec- 
essary to  the  development  of  nymphomania,  for  it  has 
been  known  to  occur  in  individuals  who  had  neither 
masturbated  nor  indulged  in  sexual  intercourse.  Some 


262 


of  the  most  painful  cases  of  the  disease  have  occurred 
during  pregnancy.  The  principal  astonishing  feature 
of  such  unfortunate  cases  is  the  acquirement  of  lewd 
actions  and  expressions  on  the  part  of  women  previ- 
ousl}^  and  naturall}'  pure-minded  and  refined.  Such 
women  may  use  expressions  and  commit  actions  that 
lead  the  physician  to  wonder  where  they  the}'  possibly 
have  acquired  a knowledge  of  them. 

The  gynecologist  is  crapelled  to  be  on  his  guard 
with  reference  to  a not  infrequent  form  of  nympho- 
mania, but  one  which  is  little  suspected  by  those  sur- 
rounding the  patient,  in  which  the  woman  develops  a 
fondness  for  gynecological  manipulations.  The  sub- 
terfuges and  devices  of  such  patients  to  induce  hand- 
ling of  the  sexual  organs  on  part  of  the  physician  are 
something  remarkable.  Perhaps  one  of  the  most  fre- 
quent forms  of  this  malingering  is  the  pretense  of 
retention  of  urine  ; although  every  disease  which  thev 
may  have  heard  of  will  be  complained  of  by  such 
patients  in  their  insane  endeavors  to  obtain  manipula- 
tions at  the  hands  of  gynecologists. 

Howe  relates  an  interesting  case  of  this  kind  occur- 
ring under  his  observation  at  Bellevue  Hospital : 

“A  girl,  aet.  18,  was  admitted,  supposed  to  be  suffer- 
ing from  retention  of  urine.  She  was  thin;  her  eyes 
were  deep  set,  but  bright  and  staring,  and  were  found 
filled  with  tears.  Her  statement  was  that  she  had 
passed  no  water  for  three  days;  that  she  was  subject 
to  these  attacks,  and  was  treated  by  having  her  water 
drawn  off.  I introduced  the  catheter,  and  found  only 
a few  ounces  of  urine  in  her  bladder — not  enough,  in- 
deed, to  corroborate  her  history.  The  next  morning, 
as  she  had  not  urinated  during  the  night,  I drew  off 
the  urine  again.  While  doing  so  I noticed  by  a se- 
ries of  peculiar  convulsive  movements,  that  she  was 
under  the  influence  of  strong  excitement.  Further 
examination  showed  that  the  labia  minora,  clitoris  and 
adjacent  parts  were  red  and  swollen  and  bathed  in  a 
profuse  mucous  secretion.  I then  remembered  that 


263 

on  the  previous  evening  she  had  shown  a somewhat 
similar  state  of  excitement,  and  gave  the  nurse  orders 
to  watch  her  closely  all  day.  In  the  evening  the  nurse 
informed  me  that  the  patient  kept  up  a constant  fric- 
tion of  the  genitals  when  she  supposed  no  one  was 
watching,  and  even  when  eyes  were  on  her  she  en- 
deavored, by  uneasy  movements  in  the  bed,  to  con- 
tinue the  titillation.  Knowing  then  what  I had  to  deal 
with,  the  patient  was  given  a sedative,  and  was  told 
that  she  must  empty  her  bladder  without  assistance. 
For  thirty-six  hours  subsequently  she  obstinately  in- 
sisted on  her  inability  to  urinate.  When  she  was  told 
no  catheter  would  be  emplo)'ed  again  there  was  no 
further  retention.  Soon  after  she  left  the  hospital  I 
learned  that  a physician  friend  of  mine  was  treating 
her  for  uterine  disorder,  but  he,  too,  soon  found  out 
the  true  nature  of  the  case,  and  advised  her  to  get 
married.” 

Several  cases  of  a similar  nature  have  come  under 
my  own  observation,  one  during  my  hospital  experi- 
ence, and  two  others  in  private  practice. 

The  treatment  of  satyriasis  and  nymphomania  con- 
sists chiefly  in  the  removal  of  irritation  of  the  sexual 
apparatus,  the  administration  of  anaphrodisiac  reme- 
dies to  be  hereafter  considered,  and  attempts  to  re- 
strain sexual  excesses,  or  to  break  the  habit  of  mas- 
turbation, as  the  case  may  be.  Where  there  is  actual 
organic  disease  the  case  is  likely  to  be  found  to  be  in- 
curable in  the  majority  of  instances,  particularly  if  the 
structural  disease  involves  the  nervous  centers.  In 
women,  the  extirpation  of  the  ovaries,  or  the  proced- 
ure of  Mr.  Baker  Brown — clitoridectomy  may  be  per- 
formed. Howe  recommends  the  application  of  the 
actual  cautery  to  the  back  of  the  neck.  Basing  this 
treatment  upon  the  theory  that  the  disease  takes  its 
origin  in  over-excitation  of  the  nerve  fibers  of  the  cer- 
ebellum or  some  of  the  ganglia  in  the  neighborhood, 
he  also  suggests  blisters  and  setons  to  answer  the 
same  purpose.  Dry  cupping  to  the  nucha  is  also  ser- 


264 

vicable.  Means  to  restore  the  general  health  are  al 
ways  indicated.  In  the  severe  cases  of  the  maniacal 
form  of  excessive  sexual  desire,  the  asylum  is  usually 
our  only  recourse. 


URETHRAL  AND  GENITAL  NEU- 
ROSES. 


'.'.here  are  a few  morbid  conditions  of  a functional 
character  which,  al chough  oftentimes  an  integral  part 
of  organic  diseases  of  the  organs  which  it  is  my  spe- 
cial province  to  consider,  are  occasionally  either  mor- 
bid entities  or  else  the  prominent  source  of  complaint 
on  the  part  of  the  patient,  indeed  we  are  apt  to  be 
more  often  consulted  regarding  these  functional  or 
nervous  derangements  than  the  diseases  upon  which 
they  frequently  depend. 

There  is,  perhaps,  no  subject  in  the  whole  range  of 
genito-urinary  disturbances  of  greater  importance 
than  the  varied  phenomena  involving  nervous  de- 
rangements that  are  due,  directly  or  indirectly,  to 
pathological  conditions  of  the  various  portions  of  the 
urethral  canal.  It  is  certain,  also,  that  in  no  class  of 
cases  which  come  under  the  observation  of  the  genito- 
urinary surgeon,  is  an  accurate  diagnosis  of  greater 
importance,  or  more  difficult  to  accomplish.  I feel, 
therefore,  that  a contribution  to  the  special  slud}^  and 
treatment  of  such  cases  is,  to  say  the  least,  warrant- 
able. 

When  we  consider  the  vast  amount  of  labor  and  tale7it 
that  have  been  devoted  to  the  study  of  the  reflex  neuroses 
of  the  female  due  wholly  or  in  fart  to  pathological  ente- 
ties  aflhecting  the  uterus  and  its  appendages,  it  is  certainly 
surprising  that  more  attention  has  not  been  given  to  anal- 
ogous conditions  in  the  male  due  to  disturbances  of  the 
generative  orga?is  and  especially  of  the  urethra. 

Taking  as  our  point  of  departure  the  prostate  body, 
we  will  find  quite  a close  similarity  between  some  of 
its  morbid  conditions  and  those  affecting  the  uterus. 
Physiologically,  the  prostate,  or  at  least  a portion  of 
it,  is  the  homologue  of  the  uterus,  there  being  the 
closest  resemblance  in  the  muscular  structure  of  the 


— 266  — 


two  bodies.  If  the  muscular  tissue  becomes  perverted 
in  growth,  we  have  in  the  one,  uterine  myoma,  and 
in  the  other,  prostatic  hypertropy,  the  structure  of 
the  two  morbid  processes  being  strikingly  similar. 
When,  as  is  occasionally  the  case,  the  “third  lobe” 
of  the  prostate  becomes  so  circumscribed  as  to  form 
a distinct  tumor,  it  is  generally  not  unlike  a peduncu- 
lated fibroid.  It  will  also  be  found  that  certain  rem- 
edies which  have  a pronounced  action  upon  unstriated 
muscular  fiber,  have  a somewhat  similar  action  upon 
the  prostate  and  uterus,  this  being  especially  true  of 
secale,  ustilago  maidis,  and  hammamelis.  Certain 
sedative  remedies  act  very  similarl}'  upon  irritative 
affections  of  the  uterus  or  ovaries  and  the  prostate. 
To  carry  the  argument  a little  further  and  directly  ap- 
proach the  subject  of  neuroses,  it  will  be  found  that 
certain  irritations  affecting  the  prostate  will  produce 
effects  quite  like  those  produced  by  utero-ovarian  ir- 
ritation in  women.  False  spermatorrhcea  (spermato- 
phobia)  pseudo-impotency  involving  disgust  for  the 
sexual  act,  melancholia,  hypochondria,  neuralgias 
wdiether  of  the  contiguous  or  remote  nervous  fila- 
ments, and  nervous  inhibition  amounting  to  almost 
complete  paresis,  are  all  possible  results  of  urethral 
or  prostatic  irritation,  and  these  conditions  are  all 
represented  by  similar  disturbances,  such  as  hysteria 
and  allied  coirditions  in  the  female,  due  to  morbid 
conditions  of  the  generative  organs.  The  analog}' 
between  the  results  of  prostatic  catarrh  and  those  of 
cervical  catarrh,  as  shown  in  one  of  the  cases  here- 
with reported,  is  sometimes  especiallv  striking. 

One  of  the  interesting  features  of  stricture  of  the 
urethra  is  the  ensemble  of  symptoms  of  a nervous 
character  that  is  so  often  seen,  and  which  neuroses 
are  frequently  entirely  disproportionate  to  the  degree 
of  organic  trouble  present.  Cephalalgia,  neuralgia 
in  various  localities,  particular!}'  sciatica,  lumbar  and 
intercostal  neuralgia,  are  quite  common,  but  are  prob- 
ably regarded  by  both  physician  and  patient  as  coin- 
cidences rather  than  as  bearing  an}'  consequential 


■ — 267  — 


relation  to  the  stricture.  Associated  with  these  are 
others  (quite  as  prominent  in  some  cases)  of  a purely 
mental  character,  such  as  melancholia,  hypochondria, 
disturbed  sleep,  incapacity  for  intellectual  effort,  and 
deterioration  of  business  capacity,  perhaps  associated 
with  great  irritability  of  temper.  Disturbed  digestion 
and  general  faulty  nutrition  are  constant.  That  these 
various  morbid  conditions  depend  upon  the  stricture 
is  never  fully  appreciated  until  that  organic  entity  is 
cured,  when  the  complete  restoration  to  health  dem- 
onstrates their  true  relation  to  the  primary  source  of 
irritation.  Many  of  my  patients  tell  me  that  they  had 
become  so  accustomed  to  their  little  ailments  that 
the}'  had  come  to  consider  them  a matter  of  course 
and  had  never  dreamed  of  their  association  with  the 
stricture  until  the  latter  was  cured.  One  of  my  pa- 
tients remarked  that  he  did  not  know  how  sick  he 
was  until  he  had  been  cured  of  his  stricture. 

Certain  cases  of  gleet  are  associated  with  consider- 
able mental  depression  which  is  commonly  attributed 
to  the  moral  effect  of  the  supposed  drain  upon  the 
system.  This  mental  disturbance  I believe  to  be  in 
many  instances  the  result  of  reflex  irritation  through 
the  sympathetic  system,  which  is  so  closely  associated 
with  the  functions  and  nutrition  of  the  sexual  organs. 

Morbid  conditions  of  the  urethra  not  only  cause 
neuroses  in  other  portions  of  the  body,  but  they  are 
often  a reflex  result  of  disease  of  contiguous  struc- 
tures; thus  I have  noted  cases  of  spasmodic  strictiue 
dependent  upon  hernia  and  varicocele.  Dr.  Otis  has 
described  some  very  interesting  cases  of  chronic 
spasmodic  stricture  of  reflex  origin.  Operations  about 
the  anus  are  very  often  followed  by  spasmodic  stric- 
ture and  urinary  retention.  Morbid  conditions  of  the 
anterior  portions  of  the  urethra  often  cause  reflex  dis- 
turbances of  the  deeper  portion  of  the  canal,  or  in- 
deed, of  the  bladder.  This  is  very  familiar  in  con- 
nection with  the  results  of  contraction  of  the  meatus. 

One  of  the  most  annoying  complaints  which  the 
surgeon  is  called  upon  to  treat  in  connection  with  the 


— 268  — 


genito-urinary  apparatus,  and  especially  in  stricture, 
is  neuralgia  and  hyperaesthesia  of  the  urethra.  This 
disorder  is  most  often  the  result  of  long  standing 
urethral  inflammation,  or  stricture  with  its  attendant 
gleet,  and  frequently  persists  long  after  organic  dis- 
ease has  apparently  been  cured.  The  majorit}'  of 
patients  who  suffer  from  urethral  neurosis  of  this  kind 
are  either  of  an  emotional  and  highly  sensitive,  nervous 
organization  — often  simulating  “hysteria”  in  the 
male — or  of  a gouty  temperament  with  highly  acid 
and  concentrated  urine;  anaemic  and  cachectic  patients 
are  especially  liable  to  it  if  nervous  or  rheumatic.  In 
such  patients  the  imagination  has  been  overwrought 
by  the  dread  of  serious  results  from  urethral  disease, 
and  the  mind  depressed  by  a sense  of  self-degrada- 
tion. The  condition  of  the  mind  as  well  as  that  of 
the  urethra  has  been  impaired  by  long-continued 
treatment  of  something  which  although  trifling  in 
itself,  perhaps,  is  to  the  patient  a terrible  morbid 
entity,  and  a mental  incubus  from  which  he  is  never 
free  except  during  the  hours  of  sleep  Quack  litera- 
ture, irritating  injections,  over-enthusiastic  treatment, 
sexual  starvation  and  excitement  without  gratifica- 
tion, are  all  disturbing  elements  in  his  case,  and  if 
we  superadd  the  results  of  dissipation,  intemperance 
and  dietetic  errors,  what  wonder  is  there  that  he  never 
gets  well,  or  that  he  magnifies  the  slightest  unusual 
sensation  about  his  sexual  organs  into  something 
new,  serious  and  startling.  Such  patients  will  say  to 
us  when  we  tr}^  to  convince  them  that  their  gonor- 
rhoea, gleet  or  stricture  is  practically  well:  “But. 

doctor,  I am  not  quite  right.  I have  a funny  feeling 
at  this  point  in  the  canal,”  or  the  complaint  will  be 
varied  by  a description  of  severe  burning  or  cutting 
pains  in  the  canal  during  micturition,  or  a tender 
spot  usually  near  the  meatus.  Sometimes  the  pain 
radiates  to  the  other  portions  of  the  sexual  organs. 
On  examination  with  the  urethroscope  nothing  ap- 
pears which  will  account  for  the  trouble;  and  treat- 
ment is  usually  of  little  avail,  unless  we  succeed  in 


269  — 


obtaining  the  patient's  conlidence  and  inducing  him 
to  believe  that  his  trouble  is  not  organic  and  will  soon 
wear  av/ay — only  too  often,  however,  he  goes  from 
surgeon  to  surgeon  in  the  vain  endeavor  to  find  relief, 
until  despairing  and  disgusted  he  resigns  himself  to 
what  he  considers  inevitable  fate  and  lapses  into  con- 
firmed melancholy  and  hypochondria.  Great  irrita- 
bility of  mind  alternating  with  depression  and  mel- 
ancholia. Morbid  atates  of  the  prostatic  sinus  and 
vesical  neck  with  or  without  coexisting  stricture  occa- 
sionally give  rise  to  urethral  neuralgia;  vesical  calculus 
and  tumors  are  especially  liable  to  be  complicated 
by  it.  Hyperesthesia  of  the  urethra  is  so  often 
associated  with  stricture  and  gleet  that  it  is  worthy 
of  consideration  in  every  case  in  which  obstructive 
spasm  occurs  during  instrumentation;  some  canals 
will  be  found  to  be  so  hyperesthetic  that  a chronic 
spasmodic  condition  exists.  ■ In  some  cases  of  chronic 
spasmodic  stricture  or  urethrismus,  local  lesions  of 
the  mucous  membrane  exist,  while  in  others  nothing 
abnormal  is  to  be  detected. 

Hyperesthesia  of  the  testicle  is  an  interesting  con- 
dition which  sometimes  results  from  reflex  irritation 
from  stricture;  more  often  however  it  is  due  to  ex- 
cessive sexual  indulgence  or  the  opposite  extreme, 
i.  e.,  ungratified  and  prolonged  sexual  desire.  It  is 
most  apt  to  be  associated  with  cachexiae,  gout,  neuras- 
thenia or  anaemia.  The  testicle  may  be  relaxed  and 
soft,  or  full  and  firm  to  the  feel.  Oftentimes  vari- 
cocele is  present  and  acts  as  an  efficient  cause  for  the 
affection.  Hypochondria,  melancholia  and  various 
mental  perversions  of  a delusional  character  are  not 
unusual,  and  may  perhaps  be  associated  with  a slug- 
gish portal  circulation  or  dyspepsia.  Sudden  depriva- 
tion of  customary  sexual  indulgence  is  said  by  Curling 
to  be  a frequent  cause. 

The  symptoms  consist  in  extreme  sensibility  and 
tenderness  either  of  the  entire  testicle  or  some  spot 
upon  its  surface.  So  exquisitely  tender  is  it  that 
oftentimes  the  contact  of  the  clothing  and  the  various 
bodily  movements  cannot  be  borne. 


— 270  — 


Neuralgia  of  the  testicle  is  really  an  exaggeration 
of  hyperaesthesia,  and  has  in  addition  to  h}-per-sensi- 
tiveness,  paroxysms  of  shooting  cutting  pain  in  the 
organ.  The  causes  are  much  the  same  as  for  hj’per- 
aesthesia — syphilis,  gout,  and  malaria  having  a promi- 
nent place  in-  its  aetiology.  Urethral  stricture  quite 
often  and  prostatic  and  bladder  disorders  occasionally 
cause  it.  The  pain  is  much  like  that  of  renal  colic 
and  is  sometimes  attended  by  retraction  of  the  testis 
from  spasm  of  the  cremaster  and  the  sick,  faint  feel- 
ing and  cold  perspiration  characteristic  of  shock.  I 
believe  that  some  cases  are  really  due  to  irritation  of 
the  renal  pelvis  and  ureter  by  sharp  crystals  in  the 
urine,  and  this  acting  reflexly  produces  pain  in  the 
testis.  Usually  only  one  testis  is  involved.  As  a rule 
the  patient  can  walk  about,  but  in  the  severe  cases  he 
is  apt  to  be  greatly  prostrated,  and  in  addition  he 
usually  suffers  from  pain  and  soreness  on  movement. 

The  treatment  of  the  neuroses  which  have  been 
presented  consists  in  following  some  ver}-  plain  indi- 
cation as  well  as  putting  in  practice  numerous  gen- 
eral principles.  First  and  most  important  of  all  is 
attention  to  the  patient’s  mental  condition.  His  mind 
should  be  diverted  from  his  physical  ills,  and  at  the 
same  time  kept  free  from  all  sources  of  sexual  dis- 
quiet. Questionable  literature  and  the  society  of 
loose  women  must  be  avoided;  in  short,  an  attempt 
should  be  made  to  correct  the  impression  so  preva- 
lent among  men,  that  man’s  chief  mission  upon  earth 
is  the  procurement  of  material  wherewith  to  cloy  his 
sexual  appetite.  Once  dispel  the  idea  that  his  penis 
and  testes  constitute  the  axis  around  which  his  earthly 
existence  revolves,  and  one  will  have  done  more  for  his 
patient  than  if  he  had  fed  him  the  entire  contents  of  a 
drug  store.  Having  allayed  sexual  disturbances  of  a 
purely  mental  or  moral  character,  it  remains  for  us  to 
secure  for  our  patient  phj’sical  sexual  rest,  it  being 
sometimes  a matter  of  nice  judgment  to  determine 
whether  moderation  or  strict  continence  is  best  for  the 
patient’s  welfare.  In  a general  way  it  may  be  said 


that  those  neuroses  which  are  dependent  upon  or 
complicated  by  actual  inflammation,  acute  or  chronic, 
demand  absolute  continence,  while  in  those  of  a purely 
nervous  character,  moderation  is  to  be  advised.  It  is 
always  a hard  matter  to  determine  the  degree  of  suc- 
cess of  our  prescription  in  this  matter,  as  the  pa- 
tient’s penis  is  not  only  quite  liable  to  gain  the 
mastery  over  his  reason  and  judgment,  but  over  his 
morals  as  well,  and  he  will  therefore  be  apt  to  consider 
that  a lie  to  his  doctor,  like  Rip  Van  Winkle’s  drink, 
doesn’t  count. 

Second  only  to  sexual  rest  is  the  correction  of  urinary 
activity.  This  may  he  corrected  by  diet  and  remedies 
combined,  the  diet  being  by  far  the  most  important.  The 
proper  standard  for  a suitable  diet  is  bread  and  milk, 
but  this  may  be  varied  within  narrow  limits.  Nitro- 
genized  food,  stimulants  and  tobacco  must  be  strictl}^ 
prohibited.  As  an  adjuvant  to  this  regimen,  the 
Turkish  bath  does  excellent  service. 

The  best  remedies  to  correct  hyperacidity  of  the 
urine,  are  the  acetate  and  citrate  of  potassium,  liquor 
potass.,  and  in  gouty  or  rheumatic  patients  (who  are 
especially  liable  to  neurotic  symptoms  from  urinary 
disturbances)  lithia,  colchicum,  and  salicylic  acid. 
Mineral  waters  are  very  useful,  the  Buffalo  lithia  and 
Waukesha  waters  being  especially  useful.  Several 
of  my  patients  claim  great  benefit  from  partaking 
freely  of  the  Geneva  magnetic  water. 

Sedatives  and  anti-spasmodics  are  often  useful  in 
these  cases,  the  following  being  of  service  in  different 
cases,  viz. : potassium  bromide,  gelsemium,  hyoscya- 
mus,  camphor  monobromate,  morphia,  salix  nigra  and 
ergot.  Tonics  are  often  required,  the  best  being  the 
chloride  of  iron,  strychnine,  arsenic  and  quinine.  In 
those  rare  cases  of  spasmodic  stricture  of  malarial 
origin,  quinine  is  of  course  a specific.  Three  ver}' 
useful  drugs  are  the  phosphide  and  bromide  of  zinc, 
and  the  bromide  of  arsenic,  these  being  great  favor- 
ites of  my  owm. 

In  many  cases  of  urethral  neurosis,  surgical  mter- 


— 272  — 


ference  is  required,  thus  a contracted  meatus  must  be 
cut,  a stricture  dilated  or  cut,  hernia  or  a varicocele 
operated  upon  or  properly  supported,  etc.  The  para- 
mount indication  from  a surgical  stafidpoint,  is  the  relief 
of  obstructive  and  inflammatory  lesions  of  the  genito- 
urinary tract. 

Cases  of  irritability  and  hyperaesthesia  of  the  testes 
are  by  no  means  promising.  The  use  of  anodynes  is 
ordinarily  reprehensible,  as  the  disease  is  chronic  in 
character  and  a narcotic  habit  ma}'  be  readily  ac- 
quired. If  hygiene,  the  steel  sound,  the  suspensor\' 
bandage  cind  marriage  do  not  cure,  the  case  is  apt  to 
be  hopeless.  Galvanism  and  the  application  of  ice 
bags  are  said  to  be  of  service.  Castration  is  not  to  be 
thought  of,  but  the  idea  suggests  itself  to  me  that  in 
an  obstinate  case,  stretching  the  spermatic  cord  with 
incisions  into  the  tunica  albuginea  might  be  successful 
in  curing  the  neuralgia.  Hammond  suggests  pressure 
upon  the  cord  for  the  relief  of  the  obstinate  cases, 
upon  the  theory  that  in  this  way  the  - sensibilit}'  and 
conductivity  of  the  affected  nerve  fibers  will  be 
obtunded. 

A very  interesting  case  showing  the  great  annov- 
ance  which  may  reflexly  arise  from  slight  irritation  of 
the  genito-urinar}^  tract  came  under  my  observation  a 
few  days  ago.  A gentleman  28  }-ears  of  age  had  been 
troubled  by  frequent  micturition,  especiall}^  at  night, 
for  some  years.  At  times  he  would  be  compelled  to 
rise  four  or  five  times  at  night  to  evacuate  his  bladder. 

The  only  point  in  his  histor}^  of  any  importance 
was  a gonorrhoea  some  seven  or  eight  }'ears  ago.  He 
confessed  to  masturbation  and  se.xual  excess  in  times 
past,  but  stated  that  sexual  apath}'  and  incapacity 
had  prevailed  of  recent  years.  On  examination  I saw 
a meatus  which  had  been  badl}^  cut  b}'  some  surgeon 
one  year  ago.  Just  within  it  was  a very  irritable  and 
resilient  stricture  of  a caliber  of  twenty  Fr.  Not  a 
stricture  perhaps,  in  the  e}'es  of  some  surgeon,  but  a 
decided  stricture  in  my  opinion.  This  contraction 
was  so  irritable  that  attempts  at  exploration  threw 


— 273  — 


the  entire  canal  into  a state  of  spasmodic  contraction. 
I found  it  impossible  to  pass  a bougie  through  the 
deep  portion  of  the  canal.  Cocaine  was  applied  and 
a meatotomy  at  once  performed.  As  soon  as  the  mea- 
tus was  free,  I passed  a 32  Fr.  solid  steel  sound  into 
the  bladder  without  the  slightest  effort.  The  night  of 
the  operation  the  patient  had  the  first  uninterrupted 
sleep  that  he  had  enjoyed  for  }^ears,  this  experience 
being  repeated  every  night  following  until  he  left  for 
his  home  in  the  west. 

We  have  here  a case  of  vesical  and  prostatic  h}^- 
perassthesia,  and  chronic  spasmodic  stricture — ure- 
thrismus — instantly  relieved  by  removing  the  reflex 
sources  of  irritation,  a resilient  irritable  meatal  con- 
traction. 

Another  interesting  case  of  a somewhat  different 
type  is  at  present  under  my  care.  This  case  shows 
how  posterior  irritation  may  reflexly  excite  disagree- 
able symptoms  in  the  anterior  portion  of  the  genito- 
urinary tract.  A young  man  of  twenty-five  who  had 
suffered  from  several  severe  attacks  of  gonorrhoea, 
presented  himself  to  me  complaining  of  severe  burn- 
ing and  hot,  lancinating  pains  along  the  pendulous 
urethra,  localized  at  times  at  a point  one  inch  pos- 
-terior  to  the  meatus.  These  painful  symptoms  were 
chiefly  manifest  after  urination  although  present  in 
the  intervals.  The  patient  was  extremely  neurotic 
and  suffered  from  sexual  hypochondriasis.  Otherwise 
he  was-in  a normal  condition.  The  urine  presented 
no  pathological  features,  save  tripper  fiiden  and  mu- 
cous casts  of  the  prostatic  follicles  of  the  character- 
istic horse-shoe  nail  variety. 

Examination  with  the  bulbs  showed  a urethral  cali- 
bre of  thirty-four  French,  and  an  absolute  freedom 
from  contractions.  There  were  several  points  of  ten- 
derness in  the  penile  urethra,  and  excessive  tender- 
ness in  the  prostatic  region.  Rectal  examination 
showed  the  prostate  to  be  slightly  enlarged. 

I.  made  the  diagnosis  of  urethral  neuralgia  and  hy- 
peraesthesia  dependent  upon  posterior  urethritis  and 
follicular  prostatitis. 


— 274  — 

There  was  no  cutting  to  be  done,  and  the  treatment 
therefore  consisted  of  intermittent  dilatation  with 
large  sounds,  and  the  application  of  nitrate  of  silver 
solution  to  the  prostate.  These  applications  were 
alternated  with  the  application  of  the  continuous  cur- 
rent, positive  pole,  to  the  deep  urethra.  Internally 
tonics  were  given,  the  Tr.  ferri  chlor.  being  mainly 
relied  upon.  The  case  has  slowly  but  markedly  im- 
proved. a fact  which  is  particularly  gratifying  in  view 
of  the  stubborness  of  such  cases. 

I wish  to  state  in  passing  that  I envy  those  sur- 
geons who  have  such  brilliant  success  in  the  manage- 
ment of  this  type  of  genito-urinary  neurosis  as  is 
claimed  by  some.  Personally  I had  rather  see  the 
gentleman  with  the  cloven  hoof  walk  into  ni)'  office 
than  one  of  these  patients. 

The  explanation  of  the  obstinacy  of  such  conditions 
is  to  be  found  chiefly  in  faulty  sexual  hygiene,  a mat- 
ter over  which  we  have  but  little  control. 

As  illustrative  of  the  interesting  character  of  some 
of  the  cases  described,  I take  the  liberty  of  presenting 
the  following,  selected  from  my  case  book: 

Case  I.  Reflex  vesical  irritability  and  intercostal 
neuralgia  from  contracted  meatus.  W.  R. , age  39. 
This  gentleman  had  had  numerous  attacks  of  gon- 
orrhoea in  his  } outh,  the  last  attack  having  occurred 
about  fifteen  3^ears  ago.  Since  this  last  attack  he 
had  been  troubled  with  frequent  micturition,  necessi- 
tating his  rising  six  to  eight  times  during  the  night, 
and  causing  great  irritabilit\’  of  mind.  Micturition 
was  occasionalh'  quite  difficult,  requiring  fifteen  or 
twenty  minutes  for  its  completion,  the  stream  being 
especial!}^  slow  in  starting.  Ever}' spring  and  fall  and 
whenever  he  was  overworked  he  suffered  from  a 
severe  attack  of  pleurodynia,  which  had  been  va- 
riously diagnosed  as  pleuris}',  impending  pneumonia, 
cardiac  neuralgia,  intercostal  neuralgia,  etc.  In  two 
of  these  attacks  in  which  I attended  him.  there  was 
an  elevation  of  temperature  of  about  four  degrees, 
with  considerable  prostration,  leading  me  to  believe 


— 275  — 


that  the  attacks  were  of  a rheumatic  character.  On 
examination  of  the  urethra  , I found  the  meatus  so 
small  as  to  barely  admit  a small  probe,  and  exces- 
sively tender  and  inflamed.  A slight  gleety  discharge 
was  noticeable,  which  the  patient  stated  had  been  a 
constant  symptom  for  years.  I at  once  enlarged  the 
meatus  to  34  French,  and  attempted  a thorough  ex- 
ploration of  the  canal.  I found  that  steel  sounds 
would  not  pass  the  muscular  urethra  on  account  of 
the  intense  spasm  which  they  induced,  soft  bougies, 
however,  passed  readily  up  to  18  French.  Above  that 
size  could  not  be  passed  without  producing  intense 
pain.  No  organic  contraction  of  the  canal  could  be 
demonstrated  by  either  the  urethrameter  or  bougies  a 
bottle.  The  second  night  after  the  meatotomy,  the 
patient  slept  soundly  for  the  first  time  in  some  3^ears, 
and  he  has  continued  to  secure  his  natural  rest  ever 
since,  it  being  now  three  months  since  the  operation. 
The  flow  of  urine  has  become  quite  free,  and  starts 
as  soon  an  attempt  at  micturition  is  made,  the  act  of 
micturition  being  of  normal  frequency.  A marked 
improvement  in  the  general  health  is  noticeable  and 
the  nervous  irritability  has  in  a great  measure  disap- 
peared. There  has  been  some  increase  of  weight, 
but  as  the  patient  is  naturall}'  spare,  this  has  not  been 
very  marked.  The  attacks  of  pleurodynia  have  not 
recurred,  although  the  usual  time  for  their  occurrence 
has  passed;  and  as  time  goes  on,  I am  confident  that 
the  theory  of  their  dependence  upon  the  urethral  ir- 
ritation will  be  confirmed.  The  gleet  has  disappeared 
entirely,  and  there  has  been  a decided  increase  of 
sexual  vigor,  in  short,  as  the  patient  expresses  it,  he 
is  “ himself  ” again. 

C.vsE  II.  General  S3unpathetic  disturbance  and 
neuralgia  of  the  testes,  from  stricture  of  large  caliber 
and  follicular  prostatitis. 

J.  G.  R.,  aged  45.  This  gentleman  had  several 
attacks  of  gonorrhoea,  the  last  one  having  occurred 
some  twent3^  years  ago.  For  the  last  four  3mars  he 
had  been  suffering  with  irritation  of  the  urethra. 


ijb  — 


which  had  been  referred  to  stricture,  and  treated  by 
dilatation.  Later  on  he  had  been  “quacked”  for  dia- 
betes, prostatic  enlargement,  Bright’s  disease,  rheu- 
matism, and  several  other  afflictions,  with  no  effect 
save  to  convert  the  patient  into  a confirmed  hypo- 
chondriac. At  the  time  he  consulted  me,  he  had  been 
suffering  from  paroxysmal  pain  in  the  testes,  with  oc- 
casional “burning”  sensations  in  the  testes,  perineum 
and  cranial  vertex,  and  pains  of  a rheumatic  charac- 
ter in  the  limbs.  On  examination  of  the  urethra  I 
found  that  it  would  admit  an  i8  English  sound  quite 
readil}^,  save  some  pain  was  experienced  at  a point 
one  inch  from  the  meatus.  At  this  spot  the  bougie  a 
boule  demonstrated  the  existence  of  a linear  stricture 
of  large  caliber.  The  prostate  was  found  to  be  some- 
what tender,  but  not  enlarged.  On  examining  the 
urine  I found  that  it  contained  membranous  shreds, 
which  from  their  appearance  I judged  to  be  from  the 
prostatic  urethra,  and  the  result  of  follicular  prosta- 
titis. A slight  gleety  discharge  was  noticed,  evidently 
of  a similar  origin. 

The  meatus  and  stricture  were  cut  to  40  French, 
w'ith  a complete  relief  to  the  neuralgia  of  the  testes. 
The  rheumatism  in  the  limbs  has  greatly  improved, 
but  the  feeling  of  heat  in  the  testes,  perineum,  and 
head  has  in  a measure  persisted,  although  much  bet- 
ter. These  latter  symptoms  I attribute  to  prostatic 
irritation,  more  particularly  because  applications  to 
the  prostatic  sinus,  of  a sedative  or  astringent  char- 
acter, produce  a marked  and  speedy  amelioration  of 
them.  I have  found  also  that  the  shredd)'^  appear- 
ance of  the  urine  was  increased  by  each  application 
to  the  prostate.  Hot  boracic  acid  irrigation  has  been 
substituted  for  these  applications,  and  the  case  is 
slowly  improving.  The  connection  between  the  neu- 
ralgia of  the  testes  and  the  stricture  in  this  case  is 
demonstrated  b}^  the  improvement  resulting  from 
urethrotomy. 

Case  III.  Pseudo-impotence  from  contracted  and 
irritable  meatus.  This  case  and  case  IV.,  I will  not 
give  in  detail,  but  will  present  the  salient  points. 


— 277  — 


A young  man  of  27  had  suffered  from  several  at- 
tacks os  gonorrhoea,  the  last  of  which  ran  into  a gleet 
which  lasted  about  a year.  There  had  been  no 
irouble  with  urination,  but  about  six  months  before  I 
saw  the  patient,  he  noticed  a loss  of  sexual  power. 
He  would  suddenl}^  succeed  in  securing  an  erection 
at  times,  but  erection  would  suddenly  cease  in  the 
act  of  copulation.  On  examination  I found  the  penis 
and  testes  apparently  normal,  but  the  meatus  was 
quite  narrow  and  excessively  sensitive.  There  was 
no  deep  or  penile  stricture. 

The  meatus  was  incised  to  34  French,  and  sounds 
passed  to  the  bladder  every  third  day  for  several 
weeks.  At  the  end  of  a month  improvement  was  re- 
ported, and  in  aboui.  two  months  the  patient  reported 
himself  as  entirely'  recovered  from  sexual  disability. 

Case  IV.  Vesical  atony^  from  contracted  and  irri- 
table meatus. — This  patient,  forty^  y'ears  of  age  and 
a gambler  by  profession,  gave  the  usual  history  of 
numerous  gonorrhoeas  and  also  sy'philis.  Micturition 
had  for  a long  time  been  attended  by^  pain  and  smart- 
ing ?t  the  meatus,  and  a slight  gleet  had  been  present 
for  some  y'ears.  For  about  a year  the  stream  had 
grown  less  and  less  forcible,  until  quite  a strenuous 
effort  was  necessary'  to  empty'  the  bladder.  On  ex- 
amination the  meatus  was  found  to  be  only  moder- 
ately contracted,  but  very  tender,  the  lips  being 
everted  and  reddened.  No  deep  strictures  were  dis- 
coverable. The  feeble  flow  of  urine  through  the 
catheter  demonstrated  the  vesical  atony.  As  the  ob- 
struction was  only  moderate  and  was  congenital,  the 
atony^  was  explicable  only'  upon  the  theory' of  reflex 
spasm  of  the  cut-off  muscle  and  inhibition  of  the  de- 
trusor urinae.  Meatotomy'  to  40  French  resulted  in 
an  almost  complete  cure  as  demonstrated  by  examina- 
tion six  months  after  operation. 

Many  other  cases  of  a neurotic  character  have  oc- 
curred in  my  genito-urinary  practice,  but  these  cases 
will  serve  for  the  purpose  of  illustration.  In  all  my' 
cases,  due  attention  has  been  paid  to  general  hy'gienic 


— 2yS  — 

and  medicinal  measures,  but  the  details  of  treatment 
would  simply  result  in  prolixitj',  without  adding  to 
the  value  of  the  report.  I have  found  that  reflex 
neuralgia  of  the  testis,  penis  and  cord  and  chronic 
spasmodic  stricture  are  by  no  means  rare,  as  several 
instances  among  nw  patents  serve  to  demonstrate. 


A CASE  OF  CIRCINATE  PAPULO-ERY- 
THEMATOUS  SYPHILIDE  WITH 
PSORIASIS  PALMARIS 
SYPHILITICA.- 


Numerous  observers  have  directed  attention  to  a 
comparatively  exceptional  variety  of  papular  syphi- 
loderm,  occurring  in  the  secondary  periods  of  syphilis, 
which  assumes  a form  always  closely  resembling,  and 
frequently  precisely  identical  with,  ordinary  tinea  cir- 
cinata.  Several  beautiful  examples  of  this  form  of 
eruption  have  come  under  my  observation,  the  case 
shortly  to  be  described  being  the  most  typical  and 
clearly  outlined  of  any  that  I have  seen.  One  of  the 
first  cases  that  I encountered  in  private  practice  oc- 
curred in  a young  man  who  presented  himself  for 
treatment  for  several  patches  of  what  appeared  to  be 
ordinary  ringworm,  one  of  which  was  located  upon 
the  right  cheek,  and  the  other  upon  the  opposite  side 
on  the  neck.  Decided  pigmentation  of  these  patches 
made  me  at  once  suspect  that  they  were  syphilitic,  and 
I therefore  made  a careful  general  examination,  with 
the  result  of  discovering  gsneral  lymphatic  engorge- 
ment, a characteristic  sore-throat  and  several  mucous 
patches  upon  the  tongue.  Upon  the  roof  of  the 
mouth  were  several  distinctly  circinate,  elevated,  red- 
dish patches,  one  of  which  presented  the  arc  of  a 
circle  representing  about  one-half  the  size  of  a silver 
quarter;  the  other,  a perfect  circle,  of  the  size  of  a 
silver  dime.  The  borders  of  these  circular  patches 
were  elevated  and  of  a brighter  red  color  than  the 
normal  mucous  membrane.  The  center  of  the  patches 
was  normal  or  nearly  so,  the  membrane  possibly  being 
rather  paler  than  usual.  The  subsequent  history  of 

*Rt-‘ad  in  the  Section  on  Dermatology  and  Syphilography  of  the 
American  Medical  Association,  June  D,  189'-2. 


28o 


the  case  and  its  behavior  under  treatment  confirmed 
the  original  diagnosis  of  circinate  sj'philide. 

The  case  at  present  under  consideration  is  a ver\' 
interesting  one,  in  that  we  have  two  varieties  of  le- 


Fig.  1. 


sions  representing  two  different  stages  of  s}’philis  and 
occurring  within  a short  time  after  the  inception  of 
the  disease. 

The  patient,  a woman,  twenty-four  }’ears  of  age, 
presented  herself  at  my  clinic  at  the  suggestion  of  one 


28i  


of  my  brother  physicians.  Four  months  before  com- 
ing under  my  observation,  she  contracted  a chancre. 
This  was  followed  by  a bubo  and,  in  about  two 
months,  by  what,  from  her  description,  was  evidentl}^ 
a roseola,  interspersed  with  distinct  papular  syphilo- 
dermata.  The  first  generalized  eruption  had,  accord- 
ing to  her  storj^,  disappeared,  with  the  exception  of 
some  of  the  papules  upon  the  face  and  upon  the 
palms  of  the  hands.  These  lesions  not  only  persisted, 
but  had  increased  in  number  and  prominence.  Shortlj^ 
after  the  appearance  of  the  first  eruption,  several  mu- 
cous patches  in  the  mouth,  and  sore-throat  developed. 
The  woman  had  drunk  considerably  and  admitted  the 
cigarette  habit,  this  circumstance  amply  explaining 
the  obstinacy  of  the  lesions  under  treatment  and  the 
persistence  and  severity  of  the  lesions  of  the  mucous 
membrane  of  the  mouth  and  throat.  There  had  been, 
she  stated,  considerable  falling  of  the  hair.  Within 
three  or  four  weeks  prior  to  appearing  at  the  clinic 
the  woman  stated  that  there  had  developed  a genera- 
lized eruption  on  the  face,  which  she  thought  was 
erysipelas,  and  which  she  feared  would  extend  all 
over  the  face.  On  examining  the  patient,  I found 
upon  the  face  a number  of  distinct,  circinate  papular 
syphilodermata  of  varying  size  and  form.  Some  of 
these  presented  the  form  of  distinct  circles;  others 
were  more  or  less  crescentic  in  shape,  and  several  of 
them  were  fused  together  somewhat  like  a figure  8. 
Upon  the  back  of  the  neck,  just  at  the  roots  of  the 
hair,  there  were  two  quite  large  crescent-shaped 
lesions,  one  of  which  was  nearly  as  large  as  half  the 
circumference  of  a silver  dollar.  Upon  each  side  of 
the  face,  beginning  in  front  of  the  ear,  which  it  in- 
\ olved,  was  a syphilide  considerably  larger  than  a 
silver  half  dollar,  the  periphery  of  wdiich  was  dis- 
tinctly raised,  the  center  being  perfectly  health}'.  A 
peculiar  feature  of  these  syphilides  was  the  symmetry 
and  their  conformation  in  a general  w’ay  to  the  outline 
of  the  ear  itself.  The  elevated  portions  of  all  of  these 
lesions  were  more  or  less  seal)'.  The  nose,  upper  lip 


— -282 


%1 


»-' '.  y-:;  vj«^ 


-TKt 


Fig.  2. 


— 283  — 

and  chin  were  the  seat  of  erythema,  with  abrupt 
edges,  slightly,  if  at  all,  elevated  above  the  surround- 
ing skin.  This  erythema  underlay  a number  of  the 
circinate  syphilides  and  extended  out  upon  the  cheeks 
and  upwards  over  the  eyebrows  for  a short  distance. 
This  erythema  does  not,  I regret  to  say,  show  in  the 
appended  illustration.  The  mouth  and  throat  were 
decidedly  involved.  The  soft  palate  presented  a dis- 
tinctly circinate  patch;  the  fauces  were  congested, 
and  upon  the  right  side  an  ulcerating  mucous  patch 
was  observed.  The  tongue  was  the  seat  of  several 
inflamed  mucous  patches.  There  was  pronounced 
syphilitic  adenopathy.  The  palms  of  the  hands  pre- 
sented as  fine  an  example  of  psoriasis  syphilitica  as 
one  would  care  to  see.  This  psoriatic  eruption,  as 
will  be  seen  by  the  appended  illustrations,  was  quite 
extensive  and  plainly  marked.  Under  rigorous  mer- 
curial treatment,  with  regulation  of  the  patient's 
habits,  with  local  applications  of  mercuric  chloride 
and  tincture  of  benzoin,  the  facial  eruption  was 
speedily  removed;  that  upon  the  palms  was  quite 
stubborn,  persisting  for  several  weeks  after  the  ery- 
thema and  circinate  lesions  had  practically  disap- 
peared. 

The  circinate  papular  syphilide  has  been  described 
as  syphiloderma  papulosum  circmatum  by  Dr.  George 
H.  Fox*  and  Dr.  I.  E.  Atkinson. f Jullien;j^  describes 
it  as  syphilide  c/i  cocarde.  Kaposiy  also  describes  it  as 
a variety  of  syphilis  cutanea.  Bumstead  and  Taylor‘S 
have  described  a flat  variety  of  the  papular  syphiloderm 
which  becomes  elevated  as  a distinct  ridge  at  the 
periphery  or  as  an  annular  crest,  of  a dull  3'ellowisli 
color,  at  the  periphery  of  an  ordinary  papule.  These 
authorities  also  state  that  as  papules  retrogress,  espe- 
cially in  late  s}'philis,  the  center  of  the  lesion  mav  be 
absorbed  first,  leaving  a more  or  less  scalv  ring, 
which  is  itself  firmly  absorbed. 

^Plioto^rapinc  Illustrations  of  Cutaneous  Syphilis. 

t Joiirnal  of  Cutaneous  and  Venereal  Cir  cuses,  Vol.  I.,  No.  1. 

X Maladies  Veneriennes. 

II  Die  Haut  und  angreuzende  Schleimhaut. 

Treatise  on  Venereal  Diseases. 


— 284  — 


Professor  Atkinson’s  paper  is  illustrated  by  a beau- 
tiful example  of  the  disease,  occurring  in  a young 
negress,  and  is  one  of  the  clearest  and  most  accurate 
descriptions  of  this  peculiar  form  of  syphiloderm. 
To  this  paper  I am  chiefly  indebted  for  the  descrip- 
tion of  the  lesions. 

Atkinson  states  that  the  lesions  of  s3’philoderma 
papillosum  circinatum  develop  essentially  from  the 
annular  or  circinate  arrangement  of  the  papulo-tuber- 
culous  lesions,  so  frequentlj"  seen  upon  the  skin  in 
late  secondary  and  tertiarj^  S3'philis,  each  group  repre- 
senting a number  of  distinct  and  separate  lines 
arranged  in  a circular  form;  whereas  the  circinate 
papula-syphiloderm  invariabl3'  begins  in  a single  le- 
sion (a  papule),  from  which  the  lesion  spreads  as  the 
primary  papule  itself  disappears.  Dr.  Atkinson  has 
had  exceptional  opportunities  for  observing  negro 
patients,  and  states  that  this  peculiar  syphilide  is 
especially  frequent  in  them.  I have  had  no  opportu- 
nities to  form  an  independent  opinion  upon  this 
subject.  Atkinson’s  description  is  as  follows: 

“ In  its  milder  and  more  limited  development  it 
affects  preferably' the  face  and  neck,  but  when  exten- 
sive, no  part  seems  to  escape  it:  back,  breast,  belh'. 
thighs,  arms,  hands  become  invaded.  \\'here  tlie 
onset  is  acute  and  the  eruption  copious,  fever  ma3'  be 
present,  and  the  lesions  ma3’  form  with  almost  the 
rapidity  of  those  of  tlie  eruptive  fevers.  The  lesions 
appear  as  bright  or  dusk3’-red  discs,  but  little  elevated 
in  comparison  to  their  breadth,  and  var3'ing  in  size 
from  that  of  a small  pea  to  a diameter  of  two  centi- 
meters and  more.  Some  remain  without  further 
development,  or  within  two  or  three*  da3's  begin  to 
desquamate  in  thin,  fine  scales,  beginning  at  their 
peripheries.  This  desquamation  exposes  either  a drv. 
smooth,  reddened,  and  flattened  elevation,  or  a moist 
surface  which  speedil3^  forms  a thin  straw-colored  or 
brownish  scab,  flattened  and  depressed  toward  the 
center.  After  some  da3's,  these  scabs  fall  off  and  leave 
pigmented  spots.  'While  these  changes  are  going  on 


— 285  — 


in  some  lesions,  others  exhibit  a more  curious  but  less 
intense  activity.  While  the  peripheries  of  these  pap- 
ules show  a scanty,  fine  desquamation,  their  central 
portions  gradually  sink  down  to  the  level  of  normal 
skin,  and  their  borders  extend  centrifugally.  A short 
interval  suffices  to  convert  the  former  papules  into 
unelevated  central  areas,  surrounded  by  narrow  but 
abrupt  borders  of  elevation,  forming  continuous  rings 
of  infiltration  and  continually  throwing  off  fine  scales. 
Rarely,  the  eruption  may  be  limited  to  a half-dozen  of 
these  spots,  irregularly  scattered  over  the  face,  neck 
and  shoulders. 

“The  color  of  the  central  area  will  now  be  of  a 
dusky-red  color,  slowly  fading  to  a duller  hue;  wdiile 
the  border  will  be  of  a darker  and  more  characteristic 
tint.  The  central  area  now  continues  to  grow  larger, 
and  by  the  extension  of  the  slightly  elevated  border 
all  resemblance  to  the  original  papular  lesion  is  lost. 
Instead,  there  is  presented  an  appearance  strongly 
suggestive  of  severe  tinea  circinata,  which,  indeed, 
it  may  so  closely  simulate  that,  without  the  previous 
knowledge  of  the  patient’s  syphilis,  the  lesion  may, 
upon  superficial  examination,  be  mistaken  for  ring- 
worm. The  elevated  border  will  present  a continuous 
narrow  line  of  a slightly  beaded  appearance,  and  will 
throw  off  a fine  branny  desquamation.  The  central 
portion  of  the  patch  will  usually  resume  its  normal 
surface  and  thickness,  but  there  will  remain  the 
deeper  pigmentation;  while  its  size  will  increase,  and 
its  shape  will  undergo  modifications,  altering  the 
originally  circular  outline.  In  negroes,  the  ordinar}^ 
pigmentation  of  the  patches  will  be  replaced  by  a 
simple  increased  intensity  in  the  normal  darkness  of 
the  skin. 

“These  patches  may  reach  a diameter  equal  to  that 
of  a half  dollar,  and  by  the  confluence  of  several,  great 
irregularity  of  extent  and  outline  may  be  attained.  1 
have  never  seen  any  patch  larger  than  the  size  just 
mentioned,  nor  do  I know  to  wdiat  extent  they  may 
proceed  if  uninfluenced  by  treatment.  It  is  likely, 


— 286  — 


however,  that  spontaneous  involution  would  destroy 
the  patch  before  a much  larger  extent  could  be  gained. 
In  many  patches  a curious  recrudescence  occurs  in 
their  centers,  whereby  a new  papule  forms,  and  imme- 


Fig.  3. 


diately  proceeds  to  follow  the  course  of  its  predecessor 
in  extending  peripherally,  though,  it  is  true,  the  ex- 
tending border  rarely  forms  a complete  circle,  but 
rather  a segment  of  greater  or  less  size,  and  not  so 


— 287  — 

sharply  defined  as  the  first  one.  Sometimes  a third 
papule  may  develop  Avithin  the  pigmented  inclosed 
space,  and  proceed  to  extend  in  the  same  centrifugal 
manner. 

“ But  small  provocation  is  required  to  convert  these 
lesions  into  mucous  patches,  and  when  the  axillse  or 
groins  are  invaded  the}'^  readily  become  such.  In  a 
young  Avoman,  a negress,  syphilitic  eighteen  months, 
the  papular  circinate  syphiloderm  developed  Avithin 
the  buccal  cavity,  Avhere  the  lesions,  immediately  be- 
coming mucous  patches,  adopted  the  centrifugal  ex- 
tension, the  narroAV  border  assuming  a pale,  opaline 
aspect.  Unlike  the  usual  course  of  syphilitic  cutaneous 
eruptions,  this  form,  more  especially  AAdren  the  rapid 
and  excessiA'e  exfoliation  of  the  epidermis  la}"  bare  the 
cells  of  the  Malpighian  la}"er,  Avith  the  result  of  form- 
ing thin  peripheral  or  general  crusts,  is  often  accom- 
panied by  a considerable  amount  of  itching,  as  may 
be  seen  from  the  scratch-marks  often  present.” 

Perhaps  the  most  interesting  feature  of  my  OAvn 
case  is  the  association  of  the  circinate  syphilide  of 
the  face  and  neck  Avith  the  papulo-squamous  s}'phi- 
lide  of  the  palms  of  the  hands,  popularly  knoAAm  as 
psoriasis  palmaris  syphilitica.  Such  papulo-er3'the- 
matous  lesions  as  have  been  described  are  character- 
istic of  the  secondary  period  of  the  disease  and  may 
come  on  early;  Avhereas  the  palmar  syphilide,  as  seen 
in  this  case,  usually  occurs  either  in  the  period  of 
sequelae  or  as  a late  secondary  manifestation.  The 
condition  illustrated  is  more  marked  than  is  the  ordi- 
nary papular  s}"philide  of  the  early  stages  of  the  dis- 
ease, and  it  is  much  more  obstinate  to  treatment. 
While,  in  the  case  at  present  under  consideration,  the 
lesions  of  the  palms  yielded  comparatiA'ely  easily  to 
specific  treatment,  they  Avere  A"ery  much  more  tardy 
in  disappearing  than  AA'ere  the  lesions  of  the  face. 
They  left,  moreo\"er,  an  erythematous  surface  corre- 
sponding in  area  and  form  Avitn  the  original  lesion, 
and  relapse  occurred  Avithin  tAvo  or  three  months  after 
the  infiltration  of  the  skin  had  completely  disappeared. 


288  — 


* These  de  Paris,  1891.  Aunales  de  Dermatoloprie  et  de  SyphiUs- 
graphie,  November,  1891. 


Fig.  4. 

Braiiman*  has  called  attention  to  numerous  obser- 
vations that  show  that  in  the  so-called  tertiaiy  period 
of  syphilis  there  may  appear  eruptions  unlike  most 


as  a consequence  of  dissipation  and  negligence  on 
part  of  the  patient.  The  rule  that  the  circinate  syph- 
ilide  occurs  in  the  early  period  of  syphilis  is  not  with- 
out exceptions. 


■ — 289  — 


tertiary  lesions,  which  are  deeply  situated  in  the  skin 
(tuberculo-gumma  S3’philides),  in  that  the^"  present  a 
superficial  character  and  niaj-  closely  resemble  the 
syphilides  of  the  secondary  period.  These  superficial 
eruptions  of  the  tertiary  period  present  themselves  in 
two  forms,  viz.,  a superficial  papular  eruption,  which 
is  most  exceptional,  and  an  erythematous  eruption  of 
a pale-rose  color,  a little  yellowish  in  parts,  forming 
large  circles,  or  more  frequently  lesions  of  an  oval  or 
elliptical  form.  To  the  latter  form  of  eruption  has 
been  given  the  name  erytheme  circine  tertiare.  This 
resembles  a late  roseola  of  the  circinate  form  that  has 
been  called  b}’  Fournier  7-oseola  de  retour  and  which 
may  appear  ver}"  late  in  secondary  syphilis.  This 
late  roseola  seems  to  establish  the  pathologic  connec- 
tion between  the  roseola  occurring  at  the  beginning 
of  the  secondary  period  and  the  peculiar  circinate 
erythema  of  the  so-called  tertiarj'  stage  of  the  disease. 
In  the  superficial  eruption  described  by  Brauman,  the 
lesion  almost  always  presents  itself  as  a simple 
er}^thema,  without  elevation,  and  there  ma}^  exist  a 
certain  amount  of  desquamation  of  the  very  fine  scales 
which  tends  to  be  very  stubborn,  even  if  well  treated, 
and  yields  best  to  the  mixed  treatment. 

Cases  such  as  m)^  own  show  that  a distinct  erythema 
more  or  less  generalized,  i.  e.  extending  uniformily 
over  quite  an  area  of  the  skin,  may  be  associated  with 
distinct  lesions  of  the  syphiloderma  papulosum  circi- 
natum.  This  case  also  shows  something  of  a ten- 
dency to  precocit)’,  incidental,  I presume,  to  the  bad 
personal  hygiene  of  the  patient. 


Stricture  of  the  Urethra. 


Professor  of  the  Surgical  Diseases  of  the  (xenito-Crinary  Organs  and  Sy  philology 
in  the  Chicago  College  of  Physicians  an;i  Surgeons:  Surgeon-in-Chief  to 
the  Genito-Urinary  Department  of  the  West  Side  Free  Dispensary. 
Chicago;  Fellow  of  the  Southern  Surgical  and  Gynecological  Asso- 
ciation and  of  the  Chicago  Academy  of  Medicine,  etc.:  Honorary 
Member  of  the  Texas  State  Meaical  Association,  etc.  Lectu- 
rer on  Criminal  Anthropology  in  the  Fnion  Law  School. 


This  work  is  the  most  complete  and  latest  monograph  on 
the  siibject.  It  has  several  exquisitely  colored 


BY 


FRANK  LYDSTON,  M.  D„ 


plates  and.  over  one  hundred  illustrations 
in  hlack  and  white. 


PRICE,  $3-00  (POSTPAID). 


M.  H.  Kaiifnian  Medical  Piiblishino-  Co., 


344  DEARBORN  STREET, 
Chicago,  Ir.r.. 


A ^lONOGRAPH 


ON 

Varicocele 


BY 

G.  Frank  Lydston,  M.  D., 

Professor  of  the  Surgical  Diseases  of  the  Genito-Urinary  Organs  and  Sy philology 
in  the  Chicago  College  of  Physicians  and  Surgeons:  Surgeon-in-Chief  to 
the  Genito-Urinary  Department  of  the  West  Side  Free  Dispensary. 
Chicago:  Fellow  of  the  Southern  Surgical  and  Gynecological 
Association  and  of  the  Chicago  Academy  of  Medicine, 
etc.:  Honorary  Member  of  the  Texas  State 
Medical  Association,  etc.,  etc. 

Lecturer  on  Criminal  Anthropology  in  the  Union  Law  School. 

PROFUSELY  ILI.USTRATED. 


VARICOCELE,  SEVEN  YEARS  AFTER  SCROTAL  RESECTION. 

PRICE,  \Postpaif}), 

Rexz  & Henry, 

LOUISVILLE.  KY. 


Uses.— A Specific  in  Gout 
and  Rheumatism. 

FORMULA. — Each  tablespoonful  represents  the  active  con- 
stituents of  thirty  grains  Semen  Colchicum,  thirty  grains  Phyto- 
lecca  decandra,  and  thirty  grains  Solanum  dulcamara,  AS  IODIDES 
OF  THEIR  ALKALOIDS,  and  ten  grains  of  Salicylate  Soda  with 
Aromatics.  This  preparation  has  stood  the  test  of  time  and  ex- 
perience, and  can  be  relied  upon  to  prodttce  results. 

DOSE. — One  or  two  dessertspoonfulls  every  three  hours udll  ;v- 
lieve  the  pain  of  Gout.,  Acute  or  Chronic  Rheumatism  in  six  hours. 


Messrs.  Renz  henry  Gentlemen:  After  diligently  test- 
ing your  “Henry’s  Triple  Hydriodates,  ' 1 can  say  “to  the  medical 
profession”  that  I have  been  a sufferer  with  Gout  for  a number  of 
years,  and  having  derived  Great  Benefit  from  your  combination, 
i can  conscientiously  recommend  it  to  the  profession  as  a sure  and 
reliable  cure  for  Gout  or  Rheumatism  that  was  not  relieved  by  any- 
thing but  your  Solution  Tri-Iodides.  Respectfully  yours. 


GOUT.— Garrod,  Ebstein  and  Weber  and  others  attribute  an  attack  of 
Gout  to  the  accumulation  of  uric  acid  in  the  tissues.  According  to  this  state- 
ment, there  must  be  a plugging  up  of  the  uriniferous  tubules  by  urates,  or  the 
uric  acid  would  be  readily  eliminated.  Garrod  also  states  that  gouty  people 
always  have  kidney  disease,  but  a chemical  and  microscopical  examination  of 
the  urine  reveals  nothing  abnormal,  only  that  just  before  an  attack  of  Gout  the 
urine  has  a very  low  specific  gravity  (l.OU)'  and  shows  an  absence  of  the  normal 
nitrogenous  constituents.  But  when  the  attack  of  Gout  comes  on.  the  urine 
becomes  concentrated,  of  a high  specific  gravity,  and  is  passed  in  very  small 
quantities.  The  urine  is  very  rich  in  nitrogenous  compounds,  and  also  contains 
a free  or  uncombined  acid,  to  w’hich  we  contend  that  the  attack  of  Gout  is  due. 
—(See  American  Practioner  ani>  News). 

This  free  acid  is  almost  immediately  precipitated  from  the  urine  of  gouty 
people,  directly  after  passing  it.  This  acid  is  but  sparingly  sohible  in  w'ater, 
but  its  aqueos  solution  has  a decided  acid  reaction  to  litmus  paper  (which  uric 
acid  has  not). 

Its  formula  from  an  ultimate  analysis  is  C.6  H.80.4  N.4  its  molecular  weight 
20U,  and  it  contains  28.28  per  cent  of  nitrogen. 

The  connection  between  Gout  and  this  acid  is  as  follows:  This  acid  is  but 
sparingly  soluble  in  warm  water,  it  is  under  certain  conditions,  such  as  a rapid 
change  in  temperature  and  exposure  to  cold,  precipitated  in  the  tissixes.  If  this 
precipitation  takes  place  in  the  muscular  coat  of  the  trachea  and  bronchus,  we 
have  asthmatic  gout;  if  in  the  heart,  we  have  cardialgi.  with  disturbances  of  the 
functions  of  this  organ:  if  in  the  joints,  we  have  arthritis. 

Colchicin  (C.6  H.8  0.4  N.4).  as  is  generally  known,  is  extracted  from  the 
meadaw  suffron  colchicum  autumnal  and  has  been  used  in  Gout  since  the  days 
of  Hippocrates;  Iodine  compounds  have  also  been  extolled  for  the  cure  of  this 
disease.  Decandrin.  is  a modern  alkaloid,  being  first  isolated  by  C.  J.  Rade- 
maker.  M.  D.,  in  1889.  from  phytolacca  decandra  (Uinne).  (See  Medical  Herald 
for  April.  1889.  Decandra  (C.8H.7N.),  molecular  weight  57,  is  a volatile  base, 
and  is  classed  with  the  amines, 

Solanin  (C.24  H.87  0.16  N.),  is  obtained  from  solanum  dulcamara. 

An  original  bottle  sent  to  any  reputable  physician,  express  prepaid.  If 
command  is  accompanied  by  post  order  for  seventy  cents.  Price  81. CO  a bottle 


LorisviLLE,  Ky'.,  January.  ISiX). 


C.  J.  Rade.makeh.  M.  D. 


Established  1832. 


LOUISVILLE,  KY. 


A TRIUMPH  IN  PHARMACY. 


ElixirXl^reeCl)lorid 


es 


^VOBARG  ET 


IDEAL  % 


'J'hc  Formula  tmmediaUly  suggests  itself  to  the  thoughtful  physieiau. 


INDICATIONS.  — Anaemia  from  any  cauee,  Struma,  latent 
Sypliilis, General  Debility,  Tuberculosis,  Malaria,  Loss  of  Appetite, 
Habitual  Constipation,  Chlororis,  Chorer,  Chronic  Uterine,  Pelvic, 
Zymotic,  Catarrhal  and  Dermatological  Diseases. 

FORMULA.  — Each  fluid  drachm  contains:  Proto-Chloride 
Iron,  one-eighth  grain;  Bichloride  Mercury,  one  hundred  and 
twenty-grain;  Chloride  Arsenic,  one  two  hundred  and  eightieth 
grain.  With  EH.xir  Calisaya  .\lkaloids  and  Aromatics. 

DOSE. — One  or  two  fluid  drachms  thiee  or  more  times  a day.  as 
directed  b.v  the  physician. 

The  physician  may  add  without  reservation  any  of  the  soluble  iodides. 

This  combination  of  three  of  the  most  potent  agreuts  at  our  command, 
so  markedly  facilitates  the  action  of  each,  that  practice  conSrms  what 
theoreticall.v  is  an  Ideal  Alterative  Tonic.  Without  tendency  to  de- 
range the  stomach  or  constipate. — Specify  R.  i H's. 


Twelve-Ounce  Bottles,  Price  $i.oo. 

Renz  5 Henry,  Drug  Importers, 


LOUISVILLE,  KY. 


Elixir  Three  Chlorides. 


Malaria,  so-called  Struma,  latent  or  unrecognized  Syphilis,  may 
all  operate  in  the  same  individual  to  bring  about  profound 
impoverishment  of  the  red  blood  corpuscles.  To  meet  this  frequent 
multiple  causation  of  Anaemia,  we  have  been  led  to  prepare  from 
the  old  and  well  tried  remedies  a tonic  which,  we  believe,  will 
immediately  appeal  to  the  judgment  and  meet  the  approbation  of 
physicians.  Our  Elixir  of  the  Three  Chlorides,  containing  as  it 
does,  the  Proto-Chloride  of  Iron,  the  Chloride  of  Arsenic  and 
and  Bi-Chloride  of  Mercury  in  small  tonic  doses,  seems  to  meet 
the  indications  as  near  as  can  be  accomplished  with  our  present 
knowledge.  With  the  Arsenic  and  Calisaya  we  aim  to  combat  the 
Malarial  element  so  often  met  as  a factor  in  Anaemia,  while  the 
small  or  alterative  doses  of  Bi-Chloride  of  Mercury  not  only  stim- 
ulate  the  glandular  system  and  promote  elimination,  but,  by  so 
doing,  are  a powerful  agent  in  reconstruction  of  the  red  blood  cells. 

At  first  glance  many  physicians  will  think  the  dose  too  small; 
however,  we  believe,  on  close  thought,  they  will  agree  that  to  get 
the  best  results  from  either  of  the  agents  employed,  viz; — the  tonic 
and  alterative  effect — they  should  be  given  in  small  doses  long  con- 
tinued. It  will  not  color  the  teeth,  is  very  pleasant  to  the  taste, 
assimilated  by  the  most  delicate  stomach,  and  harmless  under 
prolonged  use.  Please  specify  Renz  & Henry's. 


i3peiLjo  iiv[r^OFiTrE:Rs, 


(Fernim  Hydraix  et  Arsenicum.) 


Established  1832. 


LOUISVILLE,  KY. 


LINES  FROM  TALENT 

WORTH  READING. 

Elixir  Three  Chlorides — R.  & H. 


WM.  F.  KIES,  St.  Iiouis. 

Reeommends  itself  theoretioally. 

FSOF.  JKO.  A.  EASBABEE, 

Eouisville. 

The  tvipod  of  alterative  medication. 

W.T.  HOFE,M.  D.,Chattanoog'a. 

An  irresistible  formula. 

A.  M.  CABTEEDGE.ZiOuisville. 

It's  an  ideal  alterative  tonic. 

E.  B.  EE'n^IS.ia.D. .Kansas  City. 

I can  personally  endorse  it. 

T.  J.  'V7H.EIA1USOK,  M.  D., 

Eustis,  Fla. 
It's  a chemical  triumph. 
FBOF.  G.  FBANK  EYDSTON, 
CMcag'o. 

Is  a reliable  and  open  formula. 
ANGEEO  FESTOBAZZI, 

mobile,  Ala. 

I hope  its  use  will  become  moi'e  fren- 
eral. 

C.  m.  CUEVEB,  M.  D., 

Albany,  M.  Y. 

I have  obtained  the  results  I souprht. 

H.  C.  CBOWEEE, 

Kansas  City,  mo. 

The  most  valuable  of  all  alteratives 
and  tonics  I have  used. 

W.  TAYEOB  EDmiTBDS.m.  D., 
Charleston,  S.  C. 

I endorse  this  triumph  in  pharmacy. 
E.  m.  mcFHEBOir,  Denver, Colo. 
It  has  a broad  held  and  will  be 
highly  satisfactory. 

JAS.  J.  THOmAS, 

Yonug'stown,  O. 
Have  found  no  remedj-  so  efticacious 
in  Anaemia. 

C.  C.  FEBBY,  New  York,  N.  Y. 

.\s  an  alterative  and  tonic  it  cannot 
be  too  highly  e.vtolled. 

T.  FLAYFAIB  LLOYD, 

Ocala,  Fla. 
I trust  my  professional  brethern 
will  not  let  it  pass  unobserved. 
BENJ.  H.  GBOVE,  m.D. .Buffalo. 
I use  it  largely  in  mj-  private  and 
hospital  practice. 

E.  CHBISTIANSEN, 

Leavenworth,  Kas. 
Better  than  words  of  the  pen  can 
e.vpress. 

S.  E.  STBONG,  m.  D.,  Saratog-a. 

We  employ  no  alterative  combina- 
tion so  valuable  in  our  sanitarium. 

J.  A.  GILLIS,  m.  D.,  Baltimore. 

In  eczemas  the  results  were  more 
than  I expected. 


F.  E.  FOFE,  m.  D., 

Honey  Grove.  Tex. 

The  most  welcome  medicament  in 
g.vneacology. 

D.  H.  TAYLOB,  m.  D., 

Wheeling-,  W.  Va. 

It  tills  the  place  for  which  it  is 
recommended. 

DB.  F.  B.  EISEN-BOCKIUS, 

Chicago. 

.\s  an  alterative  and  tonic  gives 
solid  satisfaction. 

EUGENE  GBISSON,  m.  D., 

Denver. 

Is  entitled  to  the  confidence  of  the 
pro  fession. 

W.  B,  STEEBE,  m.  D., 

Des  moines. 

Specially  valuable  in  zymotic  dis- 
eases. 

ODELIA  BLXNN,  m.  D., 

Only  good  can  result  from  this  wise 
combination. 

DB.  HENBY  J.  BEYNOLDS, 

Chicago. 

I use  it  in  dermatology  with  most 
gratifying  results. 

W.  W.  HESTEB,  m.  D.,  Chicago. 

Is  convenient, scientific,  progressive 
and  not  disappointing. 

w.  m.  FUQUA,  m.  D., 

Hopkinsville. 

-\s  a stimulator  of  the  histogenetic 
pi-ocess  I know  nothing  better. 

E.  J.  GEISINGEB,  M.  D., 

Unionville,  mo. 

Responds  with  ,a  positiveness  and 
promptness  rarely  observed  in 
remedies. 

J.  S.  DOLSON,  m.  D., 

Hornellsville,  N.  Y. 

Charmed  and  surprised  at  immedi- 
ate benefit  in  pernicious  anaemia. 

LE  BOY  DOBBLE,  m.  D., 

Kansas  City. 

I am  much  pleased  in  specific 
keratitis  and  iritis. 

JNO.  S.  HOBNEB,  m.  D., 

Hot  Springs,  Ark. 

I have  never  been  disappointed  with 
its  use. 

F.  m.  WILSON,  m.  D., 

Bartow,  Fla. 

' You  may  rely  on  me  as  a fervent 
advocate. 

JNO.  C.  LE  GBAND, 

Alliston,  Ala. 

Worthy  the  most  favorable  consid- 
I eration. 


II 

Lydston 

1892 


